Statistics On Obesity Physical Activity and Diet England 2012

Statistics on obesity, physical activity and diet: England, 2012
Copyright 2012, The Health and Social Care Information Centre. All Rights Reserved.
The NHS Information Centre is Englands central, authoritative source of health and social care information.
www.ic.nhs.uk
Author: The NHS Information Centre, Lifestyles Statistics. Responsible Statistician: Paul Eastwood, Lifestyle Statistics Section Head Version: 1 Date of Publication: 23 February 2012
Contents
Executive Summary 1 Introduction
1.1 Obesity 1.2 Physical activity 1.3 Diet 1.4 Health Outcomes References
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9 10 11 12 14
Obesity among adults

2.1 Introduction 2.2 Overweight and obesity prevalence 2.3 Trends in obesity and overweight 2.4 Obesity and demographic characteristics 2.5 Obesity and lifestyle habits 2.6 Obesity and physical activity 2.7 Geographical patterns in obesity 2.8 The future References
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15 16 17 17 17 18 18 20 21
Obesity among children

3.1 Introduction 3.2 Trends in overweight and obesity 3.3 Relationship between obesity and income 3.4 Obesity and overweight prevalence by parental BMI 3.5 Obesity and Physical Activity 3.6 Regional, national and international comparisons 3.7 Attitudes to and knowledge of physical activity by BMI status 3.8 The future References
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23 23 24 24 25 25 26 27 28
Physical activity among adults

4.1 Background 4.2 Meeting physical activity guidelines 4.3 Physical fitness 4.4 Participation in different activities 4.5 Geographical patterns in physical activity Copyright 2012, The Health and Social Care Information Centre. All Rights Reserved.
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29 30 31 32 34
4.6 Sedentary time 4.7 Knowledge and attitudes towards physical activity References
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Physical activity among children

5.1 Introduction 5.2 Meeting physical activity guidelines 5.2.2 Objective measures of physical activity 5.3 Types of physical activity 5.4 Participation in Physical Education and school sport 5.5 Parental participation 5.6 Sedentary behaviour 5.7 Attitudes and perceptions to physical activity References
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38 38 39 40 41 42 42 43 44
Diet
6.1 Introduction 6.2 Adults diet 6.3 Childrens diet References
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45 45 48 51
Health outcomes
7.1 Introduction 7.2 Relative risks of diseases and death 7.3 Relationships between obesity prevalence and selected diseases 7.4 Hospital Episode Statistics 7.5 Prescribing References List of Tables
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52 52 53 55 57 59 60
Appendix A: Key sources Appendix B: Technical notes Appendix C: Government policy, targets and outcome indicators Appendix D: Further information Appendix E: United Kingdom Statistics Authority Assessment of the Statistics on Obesity, Physical Activity and Diet: England publication
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Executive Summary
This statistical report presents a range of information on obesity, physical activity and diet, drawn together from a variety of sources. The topics covered include: Overweight and obesity prevalence among adults and children; Physical activity levels among adults and children; Trends in purchases and consumption of food and drink and energy intake; and Health outcomes of being overweight or obese.
This report contains seven chapters which consist of the following: Chapter 1: Introduction; this summarises Government policies, targets and outcome indicators in this area, as well as providing sources of further information and links to relevant documents. Chapters 2 to 6 cover obesity, physical activity and diet and provides an overview of the key findings from these sources, whilst maintaining useful links to each section of these reports. Chapter 7: Health Outcomes; presents a range of information about the health outcomes of being obese or overweight which includes information on health risks, hospital admissions and prescription drugs used for treatment of obesity. Figures presented in Chapter 7 have been obtained from a number of sources and presented in a user-friendly format. Some of the data contained in the chapter have been published previously by the NHS Information Centre (NHS IC) or the National Audit Office. Previously unpublished figures on obesity-related Finished Admission Episodes and Finished Consultant Episodes for 2010/11 are presented using data from the NHS ICs Hospital Episode Statistics as well as data from the Prescribing Unit at the NHS IC on prescription items dispensed for treatment of obesity.
Main findings:
Obesity
In England: Just over a quarter of adults (26% of both men and women aged 16 or over) were classified as obese in 2010 (Body Mass Index (BMI) 30kg/m2 or over). A greater proportion of men than women (42% compared with 32%) were classified as overweight in 2010 (BMI 25 to less than 30kg/m2). Women were more likely then men (46% and 34% respectively) to have a raised waist circumference in 2010 (over 88cm for women and over 102 cm for men). Using both BMI and waist circumference to assess risk of health problems, 22% of men were estimated to be at increased risk; 12% at high risk and 23% at very high risk in 2010. Equivalent figures for women were: 14%, 19% and 25%. In 2010, around three in ten boys and girls (aged 2 to 15) were classed as either overweight or obese (31% and 29% respectively), which is very similar to the 2009 findings (31% for boys and 28% for girls).
In 2010, 17% of boys and 15% of girls (aged 2 to 15) were classed as obese, an increase from 11% and 12% respectively since 1995. In 2010/11, the around one in ten pupils in Reception class (aged 4-5 years) were classified as obese (9.4%) which compares to around a fifth of pupils in Year 6 (aged 10-11 years) (19.0%).
Physical Activity
In England (unless otherwise specified): In 2010, 41% of respondents (aged 2+) said they made walks of 20 minutes or more at least 3 times a week and an additional 23% said they did so at least once or twice a week in Great Britain (GB). However, 20% of respondents reported that they took walks of at least 20 minutes less than once a year or never in GB. The most popular sports activity carried out by children aged 5 to10 in 2010/11 outside school hours was swimming, diving or life saving with 48% participating in the previous four weeks. This was followed by football (36%) and cycling or riding a bike (28%). For children aged 11 to 15 the most popular sport activities participated in during the past four weeks both in and out of school were football (50%), basketball (27%) and swimming, diving or lifesaving (27%) in 2010/11. Pupils in years 1 to 13 of the schools surveyed spent an average of 117 minutes in a typical week in 2009/10 on curriculum PE. The long term trend shows an increase in the average number of minutes pupils take part in PE each week.
Diet
In England (unless otherwise specified): There has been a significant upward trend in household expenditure on eggs, butter, beverages, sugar and preserves in the UK in 2010. Household purchases of fruit fell by 0.9% in 2010 and are now 11.6% lower than 2007 in the UK. Purchases of vegetables increased by 0.4% but are 2.9% lower than in 2007. In 2010, 25% of men and 27% of women consumed the recommended five or more portions of fruit and vegetables daily. These results are similar to those reported in 2009 and are slightly lower than in 2006 when 28% of men and 32% of women consumed at least five potions daily. Between 2009 and 2010, the percentage of 5-15 year old boys consuming 5 or more portions of fruit and vegetables decreased from 21% to 19%. For 5-15 year old girls the corresponding percentages showed a similar decrease from 22% to 20%. Total energy intake per person fell 0.5% in 2010 in the UK. Total energy intake in 2010 was 2,292 kcal per person per day, in 2009 this was 2,303. Although the downward movement since 2007 is not statistically significant there is a clear picture of a longer term downward trend.
Health Outcomes
In England: In 2009, obese adults (aged 16 and over) were more likely to have high blood pressure than those in the normal weight group. High blood pressure was recorded in 51% of men and 46% of women in the obese group and in 20% of men and 15% of women in the normal weight group. The number of Finished Admission Episodes (FAEs) in NHS hospitals with a primary diagnosis of obesity among people of all ages was 11,574 in 2010/11. This is over ten times as high as the number in 2000/01 (1,054) and 1,003 more than in 2009/10 (10,571). Over the period 2000/01 to 2010/11 in almost every year more than twice as many females than males were admitted to hospital with a primary diagnosis of obesity. In 2010/11 almost three times as many women as men were admitted with a primary diagnosis of obesity (8,654 women compared to 2,919 men). North East Strategic Health Authority (SHA) had the highest rate of admissions with a primary diagnosis of obesity (40 admissions per 100,000 population) followed by the East Midlands SHA (36 admissions per 100,000 population) and London (35 admissions per 100,000 population). South West, South Central and North West SHAs had the lowest rates (14 admissions per 100,000 population). The number of Finished Consultant Episodes (FCEs) for bariatric surgery rose to 8,087 in 2010/11 12 per cent higher than in 2009/10 when there were 7,214. In the last decade, procedures saw a 30-fold increase from just 261 in 2000/01 to the current level though figures for more recent years also include procedures carried out to maintain an existing gastric band rather than fit a new one. Of the 8,087 procedures for bariatric surgery carried out in 2010/11, 1,444 were for maintenance of an existing band. The East Midlands SHA had the highest rate of FCEs for bariatric surgery per 100,000 of the population (32 procedures per 100,000 population). The North West SHA had the lowest rate (6 procedures per 100,000 population) followed by East of England and South Central SHAs (9 procedures per 100,000 population). In 2010, there were 1.1 million prescription items dispensed for the treatment of obesity, a 24% decrease on the previous year when 1.4 million items were dispensed. This is the first recorded decrease in seven years and could reflect the withdrawal from use of two of the three drugs reported on which had been used to treat obesity (sibutramine in 2010 and rimonabant in 2009).
Introduction
measuring obesity is the Body Mass Index (BMI). BMI is calculated by dividing a persons weight measurement (in kilograms) by the square of their height (in metres). In adults, a BMI of 25 to 29.9kg/m2 means that person is considered to be overweight, and a BMI of 30kg/m2 or above means that person is considered to be obese. In England, childhood obesity and being overweight is defined using the UK 1990 growth reference (as used in the sources of this report) or the UK/WHO growth reference for children under 4 years of age. This is because BMI varies with age and sex in children and adolescents. BMI is the best way we have to measure the prevalence of obesity at the population level. No specialised equipment is needed and therefore it is easy to measure accurately and consistently across large populations. BMI is also widely used around the world, not only in England, which enables comparisons between countries, regions and population subgroups. Height and weight data have been collected in each year of the HSE series, and waist circumference in most years. Height and weight data have been used to calculate (BMI); waist circumference has been used to assess central obesity. In 2006, the National Institute for Health and Clinical Excellence (NICE) produced guidelines on the prevention, identification, assessment and management of overweight and obesity in adults and children.1 These guidelines recommend a combination of BMI and waist circumference to assess health risks from obesity in adults.
This annual statistical report presents a range of information on obesity, physical activity and diet, drawn together from a variety of previously published sources. It also presents new analyses not previously published before which mainly consists of data from The NHS Information Centres Hospital Episode Statistics (HES) databank as well as data from the Prescribing Unit at The NHS Information Centre. It also includes additional analyses on the Health Survey for England (HSE) dataset. The HSE, one of the major sources of information for this report, consists of a series of annual surveys designed to measure health and health-related behaviours in adults and children living in private households in England. The survey was commissioned originally by the Department of Health and, from April 2005 by The NHS Information Centre for health and social care. The HSE has been designed and carried out since 1994 by the Joint Health Surveys Unit of the National Centre for Social Research (NatCen) and the Department of Epidemiology and Public Health at the University College London Medical School (UCL). Wherever possible, the most recent information available from the HSE is presented. See Appendix A for further detail on the HSE. The data in this publication relate to England unless otherwise specified. Where figures for England are not available, figures for Great Britain or the United Kingdom have been provided. Where relevant, links to the Scottish and Welsh Health Survey data have been provided.
1.1 Obesity
Overweight and obesity are terms that refer to an excess of body fat and they usually relate to increased weight-forheight. The most common method of In November 2010, the new coalition government set out its long-term vision for the future of public health in England in the White Paper, Healthy Lives, Healthy
People: Our Strategy for Public Health in England.2 The White Paper describes a new approach for public health in England. It also sets out examples of national level action to help tackle obesity. This includes: Continuing to run the National Child Measurement Programme, including sharing results with parents, so that local areas have information about levels of overweight and obesity in children to inform planning and commissioning of local services. Helping consumers make healthier food choices through the Change4Life3 programme. Working with business and other partners through the Public Health Responsibility Deal (see section on Diet)
1.2 Physical activity

In 2011, the UK Chief Medical Officers (CMOs) published revised guidelines for physical activity. For the first time the guidelines take a lifecourse approach, updating the guidelines for adults, children and young people and including guidelines for early years and older people. The UK CMOs recommend that adults should achieve at least 150 minutes of at least moderate intensity physical activity a week, it recognises the comparable benefits of achieving 75 minutes of vigorous intensity activity. The CMOs also recommend that children and young people should achieve a total of at least 60 minutes of at least moderate intensity physical activity each day. Start Active, Stay Active6 includes the guidelines for early years, encouraging physical activity from birth and for at least 180 minutes a day for those who are able to walk. It also includes guidelines on reducing sedentary behaviour for all age groups. Start Active, Stay Active supersedes the CMOs previous report (in 2004) on At least 5 a week: Evidence on the impact of physical activity and its relationship to health.7 In 2007, a Public Service Agreement (PSA) 22 indicator8 was introduced by the then government to deliver a successful Olympic and Paralympic Games and to get more children and young people taking part in high quality PE and sport. The PE and Sports Strategy for Young People supported the delivery of PSA22 which have now been superseded. In December 2010, the Secretary of State for Culture, Media and Sport published the coalition Governments high-level vision for achieving a lasting legacy from the Olympic Games: Plans for the Legacy from the 2012 Olympic and Paralympic Games.9 One of the key themes is to: harness the UKs passion for sport to increase grass roots participation, particularly by young people and to encourage the whole population to be more physically active.
In October 2011, the Department of Health published Healthy Lives, Healthy People: a call to action on obesity in England4 which sets out in more detail how obesity will be tackled in the new public health and NHS systems. The Public Health Outcomes Framework5 was published in January 2012. The document sets out the desired outcomes for public health and how these will be measured. The framework includes specific indicators for excess weight in adults and excess weight in 4-5 and 10-11 year olds (as well as indicators for the proportion of physically active and inactive adults and an indicator for diet). Chapter 2 on Obesity among adults in this report presents the obesity prevalence rates and trends among adults. The relationship between obesity and various factors such as sex, demographics and lifestyle habits are also explored. Chapter 3 on Obesity among children focuses on obesity prevalence rates and trends for children, and again, explores the relationship between obesity and various factors.
10 Copyright 2012, The Health and Social Care Information Centre. All Rights Reserved.
In order to tackle physical inactivity outside school, initiatives such as the Change4Life continue to be driven forward (in conjunction with tackling obesity and healthier eating). Change4Life has now expanded to focus on adults, with the Get Going Everyday10 campaign to encourage adults to increase their physical activity levels. The Government is also seeking to increase participation in sport and physical activity by working with business, the third sector and others through the Public Health Responsibility Deal11, launched on 15 March 2011. The Physical Activity Network is one of five networks created through the Deal. Chapter 4 on Physical activity among adults and Chapter 5 on Physical activity among children cover information on self reported activity and accelerometry. Physical activity levels, according to physical activity guidelines, and types of physical activity are considered. These chapters also cover information on adults and childrens knowledge and attitudes towards exercise and physical activity. Other than the HSE, other sources of information on physical activity include the latest Taking Part Survey, The National Travel Survey, The Active People Survey, The PE and Sport Survey and other fitness surveys. The Active People Survey, published by Sport England, provides information on participation in sport and recreation. It provides the data for the local area estimates of adult participation in sport and active recreation (formerly National Indicator 8).
other non-dairy sources of protein. Foods and drinks high in salt, fat and sugar should be consumed infrequently and in small amounts. This is visually represented in the eatwell plate,13 a policy tool that helps to make healthier eating easier to understand, showing the types and proportions of foods needed for a healthy, balanced diet. One of the aims of the Public Health Responsibility Deal is to tap into the potential for businesses and other organisations to improve public health and tackle health inequalities through their influence over food, alcohol, physical activity and health in the workplace. It will help deliver voluntary agreements or pledges to improve public health through activities such as further reformulation of food; better information for consumers about food; and promotion of more socially responsible retailing and consumption of alcohol. Taking forward the Department for Environment, Food and Rural Affairs (Defra) Fruit and Vegetables Task Force recommendation on fruit and vegetables, the Department of Health (DH) convened an external reference group to provide advice on possible approaches to extend the 5 A DAY logo scheme to include composite foods (i.e. those foods with more than one ingredient, one of which is a fruit or vegetable). The advice from this external reference group was provided to DH in May 2011 and options arising from this advice are being considered by DH in consultation with the food industry and Civil Society organisations. Chapter 6 on Diet covers purchases and consumption of food and drink and related intake of energy and nutrients. Also covered are adults and childrens consumption and knowledge of the recommended number of portions of fruit and vegetables a day plus attitudes towards a healthy diet.
1.3 Diet
Current government recommendations are that everyone should eat plenty of fruit and vegetables (at least 5 of a variety each day),12 plenty of potatoes, bread, rice and other starchy foods, some milk and dairy foods, meat, fish, eggs, beans and
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Other than the HSE, other sources of information on diet include the latest Living Cost and Food Survey and the National Diet and Nutrition Survey.
1.4 Health Outcomes

Chapter 7 on Health Outcomes focuses on outcomes related to being overweight or obese, in particular blood pressure. The risks of diseases linked to obesity are discussed in this chapter, as well as information on hospital episodes with a primary or secondary diagnosis of obesity, bariatric surgery and prescriptions for the treatment of obesity. Throughout the report, references are given to sources for further information which are provided at the end of each chapter. The report also contains five appendices: Appendix A describes the key sources used in more detail; Appendix B provides further details on measurements, classifications and definitions used in the various sources; Appendix C covers government policy, targets and outcome indicators related to obesity, physical activity or diet; Appendix D lists sources of further information and useful contacts and Appendix E details the requirements and suggestions made by the United Kingdom Statistics Authority (UKSA) during their assessment of this publication.
Most of the sources referred to in this publication are National Statistics. National Statistics are produced to high professional standards set out in the Code of Practice for Official Statistics. It is a statutory requirement that National Statistics should observe the Code of Practice for Official Statistics. UKSA assesses all National Statistics for compliance with the Code of Practice. Some of the statistics referred to in this publication are not National Statistics and are included here to provide a fuller picture; some of these are Official Statistics, whilst others are neither National Statistics nor Official Statistics. Those which are Official Statistics should still conform to the Code of Practice for Official Statistics, although this is not a statutory requirement. Those that are neither National Statistics nor Official Statistics may not conform to the Code of Practice for Official Statistics. During 2010, the Statistics on Obesity, Physical Activity and Diet: England publications underwent assessment by the UKSA. In accordance with the Statistics and Registration Service Act 2007 and signifying compliance with the Code of Practice for Official Statistics these statistics were recommended continued designation as National Statistics. Designation can be broadly interpreted to mean that the statistics: meet identified user needs; are well explained and readily accessible; are produced according to sound methods; and are managed impartially and objectively in the public interest.
1.5 United Kingdom Statistics Authority assessment

This statistical release is a National Statistics publication. National Statistics are produced to high professional standards set out in the Code of Practice for Official Statistics. It is a statutory requirement that National Statistics should observe the Code of Practice for Official Statistics. The United Kingdom Statistics Authority (UKSA) assesses all National Statistics for compliance with the Code of Practice.
Once statistics have been designated as National Statistics it is a statutory requirement that the Code of Practice shall continue to be observed.
The designation of National Statistics status was subject to a number of requirements. The UKSA report also contained a number of suggestions for improvement. Further details on these requirements and suggestions, including detail on how these are being addressed are contained in Appendix E.
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References
1. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence, 2006. Available at: http://www.nice.org.uk/guidance/CG43 2. Health Lives, Healthy People: Our Strategy for Public Health in England. Department of Health, 2010. Available at: http://www.dh.gov.uk/en/Publicationsa ndstatistics/Publications/PublicationsP olicyAndGuidance/DH_121941 3. Change4Life. Department of Health, 2009. Available at: http://www.dh.gov.uk/en/News/Current campaigns/Change4life/index.htm 4. Health Lives, Healthy People: A Call to Action on Obesity in England. Department of Health, 2011. Available at: http://www.dh.gov.uk/en/Publicationsa ndstatistics/Publications/PublicationsP olicyAndGuidance/DH_130401 5. Healthy lives, healthy people: Improving outcomes and supporting transparency - A Public Health Outcomes Framework. Department for Health, 2012. Available at: http://www.dh.gov.uk/en/Publicationsa ndstatistics/Publications/PublicationsP olicyAndGuidance/DH_132358 6. Start Active, Stay Active: A report on physical activity for health from the four home countries Chief Medical Officers, 2011. Available at: http://www.dh.gov.uk/en/Publicationsa ndstatistics/Publications/PublicationsP olicyAndGuidance/DH_128209 7. At least 5 a week: Evidence on the impact of physical activity and its relationship to health A report from the Chief Medical Officer, 2004. The Department of Health. Available at: www.dh.gov.uk/en/Publicationsandstat istics/Publications/PublicationsPolicyA ndGuidance/DH_4080994 8. CSR 2007 public service agreements. HM-Treasury. Available at: http://www.hmtreasury.gov.uk/d/pbr_csr07_psa22.pd f 9. Plans for the Legacy from the 2012 Olympic and Paralympic Games. Department for Culture, Media and Sport, 2010. Available at: http://www.culture.gov.uk/publications/ 7674.aspx 10. Get Going Everyday. Available at: http://www.nhs.uk/Change4Life/Pages/ daily-activity-tips.aspx 11. Public Health Responsibility Deal. Department of Health, 2011. Available at: http://www.dh.gov.uk/en/Publichealth/ Publichealthresponsibilitydeal/index.ht m 12. 5-a-day. Department of Health, 2003. Available at: http://www.dh.gov.uk/en/Policyandguid ance/Healthandsocialcaretopics/FiveA Day/index.htm 13. The Eatwell Plate. Department of Health, 2011. Available at: http://www.dh.gov.uk/en/Publichealth/ Nutrition/DH_126493
Obesity among adults

with waist circumference as the method of measuring overweight and obesity and determining health risks, specifically, the guidance currently states that assessment of health risks associated with overweight and obesity should be based on both BMI and waist circumference for those with a BMI of less than 35 kg/m2. Hence this chapter focuses on using BMI and using BMI with waist circumference in order to define overweight and obesity in adults.
2.1 Introduction
The main source of data on the prevalence of overweight and obesity is the Health Survey for England (HSE). The HSE is an annual survey designed to monitor the health of the population of England. The report is written by NatCen Social Research (previously National Centre for Social Research) and published by the NHS Information Centre (NHS IC). Most of the information presented in this chapter is taken from the recently published HSE 2010.1 This chapter focuses on the prevalence of overweight and obesity in adults, presented by Body Mass Index (BMI) and also by waist circumference. Trends in the prevalence of being overweight or being obese are presented and relationships between various economic and lifestyle variables and obesity are discussed. Regional, national and international comparisons have been provided as well as the Quality and Outcomes Framework (QOF) obesity prevalence rates. Participation by practices in the QOF is voluntary, though participation rates are very high. The chapter also includes a focus on future predictions of adult obesity, which refers to other research reports.
2.1.2 Measurement of BMI

BMI is defined as weight in kilograms divided by the square of the height in metres (kg/m2). Figure 2.1 presents the various BMI ranges used to define BMI status.
Figure 2.1 BMI definitions
Definition Underweight Normal Overweight Obese Obese I Obese II Morbidly obese Overweight including obese BMI range (kg/m ) Under 18.5 18.5 to less than 25 25 to less than 30 30 to less than 40 30 to less than 35 35 to less than 40 40 and over 25 and over 30 and over
2
2.1.1 Measurement of overweight and obesity

The calculation of BMI is a widely accepted method used to define overweight and obesity. Guidance published by the National Institute for Health and Clinical Excellence (NICE)2 postulates that within the management of overweight and obesity in adults, BMI should be used to classify the degree of obesity and to determine the health risks. However, this needs to be interpreted with caution as BMI is not a direct measure of obesity. NICE recommends the use of BMI in conjunction
Obese including morbidly obese
Where the prevalence of obesity is referred to in this chapter it is referring to those who are obese or morbidly obese (i.e. with a BMI of 30kg/m2 or over) unless otherwise stated.
2.1.3 Waist circumference

Although BMI allows for differences in height, it does not distinguish between mass due to body fat and mass due to muscular physique,
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or for the distribution of fat. Therefore, waist circumference is also a widely recognised measure used to identify those with a health risk from being overweight. A raised waist circumference is defined as greater than 102cm in men and greater than 88cm in women.
comparison 31% of men and 40% of women had a BMI in the normal range. Overall, mean BMI in men was 27.4kg/m2 and in women was 27.1kg/m2 and as with the prevalence of overweight including obesity, was higher in older age groups. Prevalence of overweight including obese varied by age, being lowest in the 1624 age group, and higher in the older age groups among both men and women. Figure 10A on page 6 of Chapter 10 the HSE 2010 report shows prevalence of overweight and obesity by age and gender for 2010.
2.1.4 NICE risk categories

NICE guidelines on prevention, identification, assessment and management of overweight and obesity highlight their impact on risk factors for developing long-term health problems. It states that the risk of these health problems should be identified using both BMI and waist circumference for those with a BMI less than 35kg/m2. For adults with a BMI of 35kg/m2 or more, risks are assumed to be very high with any waist circumference (see Figure 2.2).
Figure 2.2: NICE risk categories

Table 10.6 on page 19 of Chapter 10 of the HSE 2010 report shows the distribution of mean waist circumference and prevalence of raised waist circumference by age and gender for 2010. In 2010, 40% of adults had a raised waist circumference. Women were significantly more likely than men to have a raised waist circumference (46% and 34% respectively). Again both mean waist circumference and the prevalence of a raised waist circumference were generally higher in older age groups.
2.2.3 Health risk associated with BMI and waist circumference
2.2 Overweight and obesity prevalence

2.2.1 BMI
Chapter 10 of the HSE 2010 report provides information on anthropometric measures (height, weight, waist and hip circumference), overweight and obesity. In particular, Table 10.2 on page 14 shows BMI prevalence among adults by age and gender for 2010. The key findings show that in 2010, just over a quarter of adults (26% of both men and women) were obese, and 42% of men and 32% of women were overweight. In
Table 10.10 on pages 22 and 23 of Chapter 10 of the HSE 2010 shows the increased health risks associated with high and very high waist circumference, when combined with BMI to classify the risks (seeFigure 2.2 for definition of high and very high waist circumference). Using combined categories of BMI and waist circumference to assess overall health risk: 22% of men were at increased risk, 12% at high risk and 23% at very high risk. The equivalent proportions for women were: 14%, 19% and 25%.
2.3 Trends in obesity and overweight

2.3.1 BMI
Table 4 from the HSE 2010 Adult Trend Tables3 shows that in England the proportion of adults with a normal BMI decreased between 1993 and 2010, from 41.0% to 30.9% among men and from 49.5% to 40.4% among women. For both men and women, the proportions that were overweight were stable over the same period (approximately 40% for men and 30% for women). There was however a marked increase in the proportion that were obese, a proportion that has gradually increased over the period from 13.2% in 1993 to 26.2% in 2010 for men and from 16.4% to 26.1% for women. This increase is also shown in Figure 10E on page 10 of Chapter 10 of the HSE 2010 report (based on a 3 year moving average).
higher quintiles. For women, the proportions who were obese were higher in the lowest income quintiles and lower in the highest quintiles (ranging from 17%-34%). The relationship between BMI and income for men was less clear. Table 10.8 on page 21 of Chapter 10 of the HSE 2010 report shows that the proportion of women with a raised waist circumference was also lowest in the highest income quintile (36%) and highest in the lowest income quintile (53%). As with BMI, there was no clear relationship between waist circumference and equivalised household income for men.
2.5 Obesity and lifestyle habits

Previous years HSE reports have included more detailed exploration of the lifestyle factors associated with obesity measures. The HSE 2007 report4 included a regression analysis of the risk factors for those classified as most at risk according to the NICE categories using BMI and waist circumference criteria; the HSE 2006 report5 included a regression analysis exploring the risk factors associated with a raised waist circumference; and the HSE 2003 report6 included a regression analysis of risk factors associated with overweight and obesity. The HSE 2007 report used logistic regression (see Section 3.3.7 on pages 44 to 46 of HSE 2007 and Appendix B of this report for more details) to identify the risk factors associated with being in the most at risk categories (high or very high risk). For both men and women, being most at risk was positively associated with: age; being an ex-cigarette smoker; self perceptions of not eating healthily; not being physically active; and hypertension. Income was also associated with being most at risk, with a positive association for men and a negative association for women. Additionally, among women only, moderate alcohol consumption was negatively associated with being most at risk.

Table 5 from the HSE 2010 Adult Trend Tables shows that between 1993 and 2010, the proportion of adults with a raised waist circumference also increased, from 23% to 40% (from 20% to 34% among men and from 26% to 46% among women).
2.4 Obesity and demographic characteristics

The HSE 2010 uses equivalised household income (a measure of household income that takes account of the number of people in the household see Appendix B of this report for more details) to help identify patterns in obesity and raised waist circumference. Table 10.4 on page 17 of Chapter 10 of the HSE 2010 report shows that there were very little differences in mean BMI by equivalised household income for men; in contrast for women, those in the lower income quintiles had a higher mean BMI than women in the
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2.6 Obesity and physical activity

Self-reported physical activity levels were last included in the HSE 20087 report. Figure 2C and Table 2.5 on pages 31 and 47 of the HSE 2008 show self reported activity levels by BMI category. Both men and women who were overweight (BMI 25 to less than 30 kg/m2) or obese (BMI 30 kg/m2 or more) were less likely to meet the recommendations compared with men and women who were not overweight or obese (BMI less than 25 kg/m2). Forty-six per cent of men who were not overweight or obese met the recommendations, compared with 41% of overweight men and 32% of obese men. A similar pattern emerged for women, with 36% of women who were not overweight or obese meeting recommendations, compared with 31% of overweight and 19% of obese women. Given these findings, it is not surprising that obese men and women had the highest rates of low activity (36% and 46% respectively). Table 3.6 on page 84 of the HSE 2008 report shows the average number of minutes per day in sedentary time and all moderate to vigorous physical activity (MVPA) by BMI category based on accelerometry data (an objective measure of physical activity), and Figure 3C on page 69 shows the data for MVPA time. Those who were not overweight or obese spent fewer minutes on average in sedentary time (591 minutes for men, 577 minutes for women) than those who were obese (612 minutes for men, 585 minutes for women). Similarly, those not overweight or obese spent more MVPA minutes than those who were overweight or obese. Further information on adult physical activity linked to obesity can be found in Chapter 4 of this report.
2.7 Geographical patterns in obesity

2.7.1 Obesity and waist circumference by Strategic Health Authority
Table 10.3 on page 15 of Chapter 10 of the HSE 2010 report shows that among the different Strategic Health Authorities (SHAs) in England, no significant statistical differences were observed in men or women in mean BMI or prevalence of overweight and obesity. Table 10.7 on page 20 of Chapter 10 of the HSE 2010 report also shows there was no significant variation in the distribution of mean waist circumference or raised waist circumference by SHA.
2.7.2 Quality and Outcomes Framework

The QOF for 2010/118 includes an indicator which rewards GP practices for maintaining an obesity register of patients (aged 16 and over) with a BMI greater than or equal to 30, recorded in the previous 15 months. The recording of BMI for the register takes place in the practice as part of routine care. The underlying data includes the number of patients on the obesity register and the number of obese patients registered as a proportion of the practice list size. See Appendix A for more information on QOF. In England in 2010/11, it was calculated that the prevalence rate based on GP obesity registers was 10.5%; much lower than the 26.1% for adults reported in HSE 2010. This could be due to a number of reasons. Not all patients will be measured and there may be some obese people who have not recently visited their GP. While perhaps not able to demonstrate the complete extent of obesity prevalence, QOF can be a useful indicator of the number of people whose health is being monitored due to their obesity. To be included in the QOF obesity register a patient must be aged 16 or over and have a record of a BMI of 30 or higher in the previous 15 months. This requirement results in the prevalence of obesity in QOF being much lower than the
prevalence found in the Health Survey for England and other surveys. The Quality and Outcomes Framework (QOF) prevalence data tables for 2010/119 show a breakdown of obesity at a regional level. Prevalence rates based on the QOF ranged from 13.1% in North East SHA to 9.0% in South East Coast SHA in 2010/11. Figure 2.3 shows the obesity prevalence rates from QOF for each SHA in England in 2010/11. There is clearly a north-south divide with northern England having higher obesity prevalence rates than southern England.
Figure 2.3 Obesity prevalence rates quoted by QOF for each SHA in 2010/11 Obesity prevalence (%) 13.1% 11.5% 11.3% 10.9% 11.8% 10.3% 9.3% 9.0% 9.2% 9.9%
on pages 66 to 67 of the Welsh Health Survey 2010.12 In Scotland, 28% of adults were classified as obese, and 65% of adults were classified as being overweight or obese. In Wales, 22% of adults were classified as obese, and 57% of adults were classified as being overweight or obese. This compares with 26% of adults being obese in England and 63% of adults being overweight or obese. Details of the methodologies used by each country are contained within the publications. These will need to be considered when attempting comparisons. The Organisation for Economic Co-operation and Development (OECD) in 2011 published Health at a Glance 201113 which includes data on overweight and obese populations across different countries. Based on latest available health surveys, more than half (50.3%) of the adult population in the OECD reported that they were overweight or obese. The least obese countries were India (2.1%), Indonesia (2.4%) and China (2.9%) and the most obese countries were the US (33.8%), Mexico (30.0%) and New Zealand (26.5%). Among those countries where height and weight were measured, the overweight or obese proportion was even greater at 55.8%. The prevalence of overweight and obesity among adults exceeds 50% in no less than 19 of 34 OECD countries. Obesity prevalence has more than doubled over the past 20 years in Australia and New Zealand, and increased by half in the United Kingdom and the United States. Some 20-24% of adults in Australia, Canada, the United Kingdom and Ireland are obese, about the same rate as in the United States in the early 1990s. Obesity rates in many western European countries have also increased substantially over the past decade. The rapid rise occurred regardless of where levels stood two decades ago. Obesity almost doubled in both the Netherlands and the United Kingdom, even though the current rate in the Netherlands is around half that of the United Kingdom.
SHA North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East Coast South Central South West
2.7.3 National and international comparisons

Scotland and Wales carry out their own health surveys. Adult BMI information can be found in Section 7.5 on pages 164 and 165 and Tables 7.1 and 7.3 on pages 173 to177 of the Scottish Health Survey 2010.10 The Scottish Government also published an Obesity Topic Report11 alongside the Scottish Health Survey 2010 which investigates into the most appropriate measure of adult obesity using Scottish Health Survey data, and also investigates into the significant behavioural, socio-demographic and economic factors associated with adult obesity using data from the 2008, 2009 and 2010 surveys. Adult BMI information for Wales can be found in Section 4.7 on pages 63 to 34 and Table 4.1
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Figure 2.3.1 of the OECD report shows the prevalence of obesity among adults (2009 data) across the OECD countries and Figure 2.3.2 shows the increasing obesity rates among the adult population in OECD countries, 1990, 2000 and 2009 (or nearest years).
2.8 The future

There are various research reports and journal articles available that use HSE data to predict future obesity trends in adults. The report by Foresight at The Government Office for Science produced the Tackling Obesities: Future Choices report14 which provides a long-term vision of how we can deliver a sustainable response to obesity in the UK over the next 40 years. HSE data from 1994 to 2004 were used as a basis of modelling obesity prevalence up to 2050. By 2015, the Foresight report estimates that 36% of males and 28% of females (aged between 21 and 60) will be obese. By 2025 it is estimated that 47% of men and 36% of women will be obese. Another research report published in 2008 by the British Medical Journal Group, Trends in obesity among adults in England from 1993 to 2004 by age and social class and projections of prevalence to 201215 predicted that the prevalence of obesity will increase to 32.1% in men and 31.0% in women by 2012 based on 1993-2004 obesity prevalence trend data. The HSE 2010 data shows that the current rate is 26% for both men and women. In a couple of years we will be able to compare against these modeled estimates. The predicted 2012 obesity prevalence for adults in manual social classes is higher (34%) than adults in non-manual social classes (29%). The report also concludes that if recent trends in adult obesity continue, about a third of all adults in England (almost 13 million adults) would be obese by 2012, of which around 34% will be from the manual social class in a couple of years these estimates can also be compared against actual data.
References
1. Health Survey for England 2010: Respiratory Health. The NHS Information Centre, 2011. Available at: www.ic.nhs.uk/pubs/hse10report 2. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence (NICE), 2006. Available at: www.nice.org.uk/guidance/CG43 3. Health Survey for England 2010: Trend Tables. The NHS Information Centre, 2011. Available at: www.ic.nhs.uk/pubs/hse10trends 4. Health Survey for England 2007. The NHS Information Centre, 2008. Available at: http://www.ic.nhs.uk/pubs/hse07healthy lifestyles 5. Health Survey for England 2006. The NHS Information Centre, 2007. Available at: http://www.ic.nhs.uk/pubs/hse06cvdand riskfactors 6. Health Survey for England 2003. Department of Health, 2004. Available at: www.dh.gov.uk/assetRoot/04/09/89/11/ 04098911.pdf 7. Health Survey for England 2008. The NHS Information Centre, 2009. Available at: http://www.ic.nhs.uk/pubs/hse08physic alactivity 8. Quality and Outcomes Framework 2010/11. The NHS Information Centre, 2011. Available at: http://www.ic.nhs.uk/statistics-and-datacollections/supportinginformation/audits-andperformance/the-quality-and-outcomesframework/qof-2010-11/qof-2010-11bulletin 9. Quality and Outcomes Framework Prevalence data tables 2010/11. The NHS Information Centre, 2011. Available at: http://www.ic.nhs.uk/statistics-and-datacollections/supportinginformation/audits-andperformance/the-quality-and-outcomesframework/qof-2010-11/qof-2010-11data-tables/qof-prevalence-data-tables2010-11 10. The Scottish Health Survey 2010, Volume 1: Main Report. Scottish Government, 2011. Available at: http://www.scotland.gov.uk/Publications /2011/09/27084018/0 11. The Scottish Health Survey: Topic Report: Obesity. Scottish Government, 2011. Available at: http://www.scotland.gov.uk/Resource/D oc/361003/0122058.pdf 12. The Welsh Health Survey, 2010. Welsh Assembly, 2011. Available at: http://wales.gov.uk/docs/statistics/2011/ 110913healthsurvey10en.pdf 13. Health at a Glance 2011. Organisation for Economic Co-operation and Development, 2011. Available at: http://www.oecd.org/dataoecd/6/28/491 05858.pdf
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14. Tackling Obesities: Future Choices 2nd Edition Modelling Future Trends in Obesity and Their Impact on Health. Foresight, Government Office for Science, 2007. Available at: http://www.bis.gov.uk/assets/bispartner s/foresight/docs/obesity/17.pdf 15. Zaninotto, P. et al. (2009) Trends in obesity among adults in England from 1993 to 2004 by age and social class and projections of prevalence to 2012. Journal of Epidemiology and Community Health, 63:140-146. Available at: http://jech.bmj.com/content/early/2008/ 12/11/jech.2008.077305.abstra
Obesity among children

categorisation cannot be used to define childhood obesity as is the case with adults. Each sex and age group needs its own level of classification for overweight and obesity. The data presented in this chapter uses the British 1990 growth reference (UK90) to describe childhood overweight and obesity. This uses a BMI threshold for each age above which a child is considered overweight or obese. The classification estimates were produced by calculating the percentage of boys and girls who were over the 85th (overweight) or 95th (obese) BMI percentiles based on the 1990 UK reference population.
3.1 Introduction
This chapter presents key information about the prevalence of overweight and obesity in children aged 2 to 15 living in England, using data from the Health Survey for England (HSE) 2010.1 As described in Chapter 1, the HSE is an annual survey and has provided information about the health of children since 1995. Information is presented showing relationships between obesity prevalence and income, parental Body Mass Index (BMI) and childrens physical activity levels, and also provides regional comparisons. Information on childrens attitudes to physical activity and obesity are also included. This chapter also presents recent 2010/11 data from the National Child Measurement Programme for England (NCMP)2 which provides the most comprehensive data on obesity and being overweight among children, generally aged 4-5 and 10-11 years, based on Reception class and school year 6. The findings are used to inform local planning and delivery of services for children and gather population-level surveillance data to allow analysis of trends in weight. The final part of this chapter focuses on future predictions of childhood obesity, which refers to other research reports.
3.2 Trends in overweight and obesity

Table 11.2 on page 15, Chapter 11 of the HSE 2010 report shows that around three in ten boys and girls aged 2 to 15 were classed as either overweight or obese (31% and 29% respectively), which is very similar to the HSE 2009 findings (31% for boys and 28% for girls). Mean BMI was similar overall among girls and boys aged 2-15 (a difference of 0.1kg/m2). While mean BMI was generally similar among younger children of both sexes, the mean was higher among older girls than boys, with a gap ranging from 0.4kg/m2 to 1.1kg/m2 among those aged 12-15. Table 4 of the HSE 2010 Child Trend Tables3 shows that among boys aged 2 to 15, the proportion who were obese increased overall between 1995 and 2004 where the prevalence increased from 11.1% to 19.4%, but has steadily fallen between then and 2010 to 17.1%. Among girls in the same age group, the proportion who were obese increased from 12.2% to 18.8% between the years of 1995 and 2005 but since then has steadily decreased to 14.8% in 2010. Whilst there have
3.1.1 Measurement of overweight and obesity among children

As with adults, the HSE collects height and weight measurements to calculate BMI for each child. BMI (adjusted for age and gender) is recommended as a practical estimate of overweight and obesity in children. The measurement of obesity and overweight among children needs to take account of the different growth patterns among boys and girls at each age, therefore a universal
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been marked increases in the prevalence of obesity since 1995, the prevalence of overweight children aged 2 to 15 has remained largely unchanged and in 2010 this was 14.3% for boys and 14.4% for girls. (Note: data for 1995 to 2007 in Table 4 were revised in November 2009). The same overall obesity increase was apparent among both younger children aged 2 to 10 and children aged 11 to 15. For boys aged 2 to 10, the prevalence of obesity increased overall from 9.7% in 1995, peaking at 17.4% in 2006 but then steadily falling to 15.3% in 2010. Among girls the prevalence of obesity increased from 10.6% in 1995 to 17.4% in 2005 but had similarly decreased by 2010 to 13.9%. In the 11 to 15 age group, obesity increased among boys from 13.9% in 1995 to 24.3 in 2004, falling back to 19.9% in 2010. The situation is similar among girls, increasing from 15.5 in 1995 to 26.7% in 2004 but decreasing to 16.6% in 2010. Figure 11D on page 9 of Chapter 11 of the HSE 2010 report shows the obesity trend as a 3 year moving average. This suggests that the trend in obesity now appears to be flattening out, and future HSE data will be important in confirming whether this is a continuing pattern, or whether this is a plateau within the longer term trend which is still gradually increasing. In 2010/11, the NCMP data shows that around one in ten pupils in Reception class (aged 4-5 years) were classified as obese (9.4%) which compares to around a fifth of pupils in Year 6 (aged 10-11 years) (19.0%). Also, 13.2% of pupils in Reception class and 14.4% of pupils in Year 6 were reported as being overweight. Obesity prevalence was significantly higher in urban areas than in rural areas for both school years, as was the case in previous years. The obesity prevalence among Reception year children living in urban areas was 9.7% compared with 8.1% and 7.8% living in town and village areas respectively. Similarly, obesity prevalence among Year 6 children living in urban areas was 19.6% compared with 16.7% and 15.9% living in town and village areas respectively.
Section 13.5 on page 318 of the HSE 2008 report includes a comparison of NCMP and HSE data, outlining the differences between results and methods of collection.
3.3 Relationship between obesity and income

Figure 11B on page 6 of Chapter 11 of the HSE 2010 report shows the proportion of children who were overweight or obese in each equivalised household income quintile. Children in the highest income quintiles were least likely to be obese (14% in the highest two quintiles for boys, 12%-13% in the highest three quintiles for girls), whereas the proportion obese was highest among those in the lowest quintiles (20% in the lowest quintile for boys, 17-18% in the lowest quintiles for girls). Similarly, the proportion of children who were overweight including obese generally increased as income quintile decreased, ranging from 26% of boys and 24% of girls in the highest quintile to 35% of boys in the lowest quintile and 30-33% of girls in the lowest three quintiles
3.4 Obesity and overweight prevalence by parental BMI

Overweight and obesity prevalence among children varied by parental BMI status. The HSE 20074 (which remains the most up to date source) found that obesity prevalence rates among children were higher in households where both natural parents or lone natural parent were classed as either overweight or obese. Table 8.5 on page 239 of the HSE 2007 report shows how mean BMI, overweight and obesity prevalence varied by parental BMI status. Twenty-four per cent of boys aged 2-15 living in overweight/obese households were classed as obese compared with 11% in normal / underweight households. Equivalent figures for girls classed as obese were 21% and 10%.
3.5 Obesity and Physical Activity

Table 5.20 on page 157 of the HSE 20085 report (which remains the most up-to-date source) shows the proportion of children who were sedentary for more than four hours on a typical weekday or weekend day according to BMI categories. Among both boys and girls there was a relationship between sedentary time and BMI category, which is also shown in Figure 5I on page 132 of the HSE 2008 report. For boys, on weekdays, the proportion who spent 4 or more hours doing sedentary activities was 35% for those who were not overweight or obese, 44% of those classed as overweight and 47% of those classed as obese. For girls, a similar pattern was found; 37%, 43% and 51% respectively. Table 6.6 on page 177 of the HSE 2008 report shows average daily physical activity profile, by BMI category based on accelerometry data (an objective measure of physical activity). This shows that there is no difference in the activity profile according to whether participants were overweight or obese. However, it should be noted that the small base sizes for some of these categories limits the scope for detailed analysis. Further information on childrens physical activity linked to obesity can be found in Chapter 5 of this report.
2010/11 NCMP publication show child obesity prevalence rates in Reception class and Year 6 by Primary Care Trust (PCT). Obesity prevalence varied, ranging from 6.4% in Richmond and Twickenham PCT to 14.6% in City & Hackney PCT for Reception; and from 10.7% in Richmond and Twickenham PCT to 26.4% in Southwark PCT for Year 6. National information for Scotland and Wales can be found from their own health surveys. Child Obesity information for Scotland can be found in Chapter 7 from page 165 and Tables 7.2, 7.4 and 7.5 on pages 173 to 181 of the Scottish Health Survey 2010.6 This reports that obesity prevalence for all children aged 215 fell marginally in 2010 to 14.3% from 15% the previous year. The prevalence of obesity in boys increased from 13.0% in 1998 to 15.6% in 2010, with some fluctuations in the 20082010 period. For girls, the prevalence was 13.1% in 1998 and 12.9% in 2010, with some fluctuations in the intervening years (12.3%-14.7%). The prevalence of overweight including obesity for children aged 2-15 in 2010 was 29.9% (31.1% for boys compared to 28.5% for girls). Child obesity information for Wales can be found in Section 6 on pages 89 to 95 and Tables 6.1 to 6.6 on pages 96 to 99 of the Welsh Health Survey 2010.7 It shows that around a third of children were classified as overweight or obese, including around a fifth of children classified as obese (36% and 19% respectively). Boys were slightly more likely to be obese than girls (23% compared to 16%) with the combined overweight or obese figure for boys being 38% (34% for girls). Details of the methodologies used by each country are contained within the publications. These will need to be considered when attempting comparisons. In 2011, The Organisation for Economic Cooperation and Development (OECD) published Health at a Glance 20118 which includes data on overweight and obese populations across different countries. Based on latest available health surveys which measure height and weight, a fifth of children aged 5-17 are
3.6 Regional, national and international comparisons

Statistics derived from the National Child Measurement Programme (NCMP) in England, enables us to make regional comparisons. Obesity prevalence ranged from 8.1% in South Central Strategic Health Authority (SHA) to 11.1% in London SHA for Reception and from 16.5% in South Central SHA to 21.9% in London SHA for Year 6. The NHS Information Centre provides an online database of results by PCT. Maps in Figures 11 and 12 on pages 27 and 28 of the
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overweight or obese across all OECD and emerging countries. In Greece, the United States and Italy this figure is around one in three. In contrast, China, Korea and Turkey show overweight or obese figures of 10% or less. In most countries, boys have higher rates of overweight and obesity than girls, although girls do tend to have higher rates in Nordic countries (Sweden, Norway and Denmark), as well as in the United Kingdom, the Netherlands and Australia. The OECD reports that in many developed countries, child obesity rates doubled between the 1960s and 1980s and doubled again since then and that even in emerging countries, the prevalence of obesity is rising, particularly in urban areas. Figure 2.4.1 on page 57 of the OECD report shows the prevalence of overweight and obesity in OECD and emerging countries among school aged children (aged 5-17 years), and figure 2.4.2 presents the prevalence of overweight and obesity for 6-9 year old children. This shows that there are crucial differences among children who are overweight or obese, not only across countries but also according to their age. In general, older children have higher prevalence of overweight and obesity than younger children.
should do physical activity. In 2007, 73% of boys who were classed as obese said that children should spend a minimum of five days a week doing physical activity, compared to 62% of those in the healthy BMI category. There were no significant differences found amongst girls. When looking at the number of minutes per day children should be spending doing physical activity, 64% of boys in the healthy BMI category thought that children should spend at least 60 minutes a day doing physical activity, compared with 53% of those in the overweight category. Among girls, the proportion who thought that children should spend at least 60 minutes a day doing physical activity was higher in the overweight group: 62% among those classed as overweight compared with 50% in the healthy BMI category. Children aged 11 to 15 were also asked how they perceived their own level of physical activity compared with other children of their own age, and to state whether they would like to do more physical activity than at present.
Figure 8D on page 228 of the HSE 2007 report show that 46% of boys in the healthy BMI category believed that they were very physically active. This compares with 37% of those in the overweight group and 27% in the obese group. Among girls, 32% in the normal weight group believed that they were very physically active compared with 21% of those in the obese group.
3.7 Attitudes to and knowledge of physical activity by BMI status

At the time the data were collected the Government recommended that children should do at least 60 minutes of moderate physical activity everyday of the week. In order to assess awareness of the recommended guidelines for physical activity for their age group, children aged 11 to 15 were asked in the HSE 2007 (which remains the most up to date source) how many days a week and how many minutes a day young people should spend doing physical activity. Table 8.7 on page 240 of the HSE 2007 report shows childrens knowledge (those aged 11-15) of the number of days and minutes a day they
Table 8.8 on page 241 of the HSE 2007 report shows the proportion of children stating they would like to do more physical activity than at present was higher in the obese group than in the healthy BMI category: 71% and 57% respectively for boys, 84% and 71% for girls. In the HSE 2009, children aged 8-15 were asked about their perception of their weight. They were asked whether or not they thought they were about the right weight, and whether they were trying to change their weight. Table 11B on page 193 of the HSE 2009 shows that 75% of boys and 41% of girls who were overweight considered that they were about the right weight, and 33% of boys and 22% of
girls who were obese did so, suggesting that there was a lack of awareness of a weight problem among some children.
3.8 The future

There are various research reports and journal articles available that use HSE data to predict future obesity trends in children. The report by Foresight at the Government Office for Science, Tackling Obesities: Future Choices9 includes some predictions for the future prevalence of obesity among young people under the age of 20. This report uses the International Obesity Task Force (IOTF) definition of obesity. More information on the IOTF can be found in Appendix B. The reports predictions suggest a growth in the prevalence of obesity among people under 20 to 10% by 2015 and to 14% by 2025 based on HSE 2004 data. However, these figures should be viewed with caution due to the widening confidence intervals on the extrapolation. Another research report published in the British Medical Journal Group in 2009, Time trends in childhood and adolescent obesity in England from 1995 to 2007 and projections of prevalence to 201510 reveals that the 2015 projected obesity prevalence is 10.1% in boys and 8.9% in girls, and 8.0% in male and 9.7% in female adolescents. Predicted prevalence in manual social classes is higher than in nonmanual classes. The report concludes that if the trends in young obesity continue, the percentage and numbers of young obese people in England will increase noticeably by 2015 and the existing obesity gap between manual and non-manual classes will widen further.
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References
1. Health Survey for England, 2010. The NHS Information Centre, 2011. Available at: http://www.ic.nhs.uk/pubs/hse10report 2. The National Child Measurement Programme 2010/11: The NHS Information Centre, 2011. Available at: www.ic.nhs.uk/ncmp 3. Health Survey for England, 2010: Child Trend Tables. The NHS Information Centre, 2011. Available at: www.ic.nhs.uk/pubs/hse10trends 4. Health Survey for England, 2007. The NHS Information Centre, 2008. Available at: www.ic.nhs.uk/pubs/hse07healthylifestyles 5. Health Survey for England, 2008. The NHS Information Centre, 2009. Available at: http://www.ic.nhs.uk/statistics-and-datacollections/health-and-lifestyles-relatedsurveys/health-survey-for-england/healthsurvey-for-england--2008-physical-activityand-fitness 6. The Scottish Health Survey 2010, Volume 1: Main Report. The Scottish Government, 2011. Available at: http://www.scotland.gov.uk/Publications/20 11/09/27084018/91 7. The Welsh Health Survey, 2010. Welsh Assembly, 2011. Available at: http://wales.gov.uk/docs/statistics/2011/11 0913healthsurvey10en.pdf 8. OECD: Health at a Glance 2011, OECD Indicators. Available at: http://www.oecd.org/dataoecd/6/28/491058 58.pdf 9. Tackling Obesities: Future Choices Modelling Future Trends in Obesity and Their Impact on Health. Foresight, Government Office for Science, 2007. Available at: http://www.bis.gov.uk/assets/bispartners/fo resight/docs/obesity/17.pdf 10. Stamatakis et al (2010). Time trends in childhood and adolescent obesity in England from 1995 to 2007 and projections of prevalence to 2015. Journal of Epidemiology and Community Health, 64: 167-174. Available at: http://jech.bmj.com/content/64/2/167.abstr act

minute they are worn by the participant, allowing an objective and accurate estimation of activity to be recorded. Fitness levels were also measured using a step test. The HSE reports from 2008 to 2010 did not include questions of peoples perceptions and attitudes towards physical activity, therefore, results from the HSE 20073 remain the latest available. The Taking Part Survey (TPS)4 is a national survey of private households in England which began in mid-July 2005. It is a comprehensive study on how people enjoy their leisure time. Results from the survey include estimates on the prevalence of participation in active sport and reasons given for engagement and non-engagement in sporting activities. The National Travel Survey (NTS) 20105 provides information on personal travel in Great Britain, published by the Department for Transport, and is used in this chapter to look at the frequency of trips made by bicycle and on foot. The Active People Survey, published by Sport England, provides information on participation in sport and recreation. It provides the measurements for National Indicator 8 (NI8) adult participation in sport and active recreation, as well as providing measurements for the cultural indicators NI9, NI10 and NI11. This is an annual survey, first undertaken in 2005/06 and the latest survey presents data for 2010/116. Part of the Sport England Sport Strategy 2008-11 is a commitment to getting one million more people taking part in more sport by 2012/13.
4.1 Background
The health benefits of a physically active lifestyle are well documented and there is a large amount of evidence to suggest that regular activity is related to reduced incidence of many chronic conditions. Physical activity contributes to a wide range of health benefits and regular physical activity can improve health outcomes irrespective of whether individuals achieve weight loss. Current physical activity recommendations for adults are that they should achieve a total of at least 30 minutes of at least moderate activity, either in one session or in multiple bouts of at least 10 minutes duration, on five or more days of the week.1 Moderate activity can be achieved through walking, cycling, gardening and housework, as well as various sports and exercise (see Appendix B for further details). The main source of data used to monitor adults physical activity is the Health Survey for England (HSE). The HSE reports on adults physical activity in the four weeks prior to interview by examining overall participation in activities and by describing frequency of participation and type of activity. The HSE is used as the primary source to measure progress towards achieving physical activity guidelines. The most recent HSE that included questions about physical activity and fitness was 20082 when physical activity and fitness was the main focus of the report. In addition to the self-reported questionnaire, independent measures of physical activity were recorded in the week following the interview. Physical activity was recorded using accelerometry. Accelerometers measure the duration, intensity and frequency of physical activity for each
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4.2 Meeting physical activity guidelines

The latest information on whether physical activity guidelines are being met is derived by summarising different types of activity into a frequency-duration scale. It takes into account the time spent participating in physical activities and the number of active days in the last week. In the HSE, the summary levels are divided into three categories: Meets recommendations is defined as 20 or more occasions of moderate or vigorous activity of at least 30 minutes duration in the last four weeks (i.e. at least five occasions per week on average). This category corresponds to the minimum activity level required to gain general health benefits (e.g. reduction in the relative risk for cardiovascular morbidity). Some activity is defined as 4 to 19 occasions of moderate or vigorous activity of at least 30 minutes duration in the last four weeks (i.e. at least one but fewer than five occasions per week on average). Low activity is defined as fewer than 4 occasions of moderate or vigorous activity of at least 30 minutes duration in the last four weeks (i.e. less than once per week on average).
men and 36% of women who were neither overweight nor obese met the recommendations, followed by 41% of men and 31% of women who were overweight and only 32% of men and 19% of women who were obese. Further information is available in Chapter 2: Self-reported physical activity in adults, of the HSE 2008 and includes information on the types of activities people carry out, the average number of hours of physical activity respondents have done in the past week and the proportion of people meeting recommended physical activity guidelines by equivalised household income (Table 2.3 on page 46), Strategic Health Authority (SHA) (Table 2.2 on page 45) and spearhead PCT status (Table 2.4 on page 46). The Active People Survey 2010/11, measures the number of adults aged 16 and over in England who participate in at least 30 minutes of sport and active recreation at moderate intensity at least three times a week. This survey includes additional information on participation in sports by age, gender, ethnicity, socioeconomic classification and region. It also presents information on the types of sports people participate in and how participation levels have changed since the start of this survey. A key finding from this report is that in 2010/11, 6.927 million adults (4.245 million men and 2.682 million women) participated in sport and active recreation three times a week for 30 minutes. The key finding of the latest Taking Part Survey (TPS), 2011/12 quarter 2, is that 54.0 per cent of adults had participated in active sport at least once in the last 4 weeks. 25.8 per cent had participated in 30 minutes of moderate intensity sport at least three times in the last week, with the corresponding figure of 43.0 per cent at least once in the last week.
4.2.1 Self-reported physical activity

Self-reported physical activity in adults aged 16 and over is presented in Chapter 2: Selfreported physical activity in adults, pages 21 to 58 of the HSE 2008. Key findings from the chapter are: In 2008, 39% of men and 29% of women aged 16 and over met the governments recommendations for physical activity, compared with 32% and 21% respectively in 1997. There was a clear association between meeting the physical activity recommendations and body mass index (BMI) category. Forty six per cent of
The TPS 2011/12 quarter 2 report contains further information on the participation in sport on pages 23 to 25.
4.2.2 Objective measures of physical activity

Objective measures of physical activity in adults aged 16 and over are given in Chapter 3: Accelerometry in adults, in the HSE 2008. Accelerometers were used to independently measure physical activity over the seven day period following the completion of the self-reported physical activity questionnaire. The accelerometers record information on the frequency, intensity and duration of physical activity in one minute epochs. Full details are available in the HSE 2008 pages 62 to 66. Some key findings from the chapter are: Based on the results of the accelerometer study, 6% of men and 4% of women achieved the governments recommended physical activity level. Men and women aged 16 to 34 were most likely to reach the recommended physical activity level (11% and 8% respectively), the proportion of both men and women meeting the recommendations fell in the older age groups. On average men spent 31 minutes in moderate or vigorous activity (MVPA) in total per day and women an average of 24 minutes. However, most of this was sporadic activity, and only about a third of this was accrued in bouts of 10 minutes or longer which count towards the government recommendations.
patterns for adults on weekdays and weekend days, analyses by BMI (page 68 and Table 3.6), gender and age; as well as a comparison between the self-reported physical activity and the objective measures (pages 70 to 71 and Tables 3.10 to 3.12).
4.3 Physical fitness

Low levels of cardiovascular fitness are associated with increased risk of many health conditions. Chapter 4: Physical fitness in adults, on pages 89 to 116 of the HSE 2008, presents information on cardiovascular fitness in adults aged 16 to 74 collected using a step test and monitoring participants heart rate during and after the test. This test measured the maximal oxygen uptake (VO2max). Oxygen uptake increases rapidly on starting exercise; maximal oxygen uptake is achieved when the amount of oxygen uptake into the cells does not increase, despite a further increase in intensity of exercise. Full details of the step test, the measures of physical fitness and the definitions used in this section can be found in Chapter 4: Physical fitness in adults, on pages 91 to 95 of the HSE 2008. Physical fitness has been measured only once before on a nationally-representative sample in England. In 1990, the Allied Dunbar National Fitness Survey (ADNFS),7 tested participants fitness on a treadmill, by measuring VO2max. The information in the HSE 2008 was analysed to allow comparisons to be made between the HSE 2008 and the ADNFS and this involved converting the results of the step test from the HSE to indicate the percentage of adults who could sustain walking at 3 miles per hour (mph) on the flat and on 5% incline. The key findings from this chapter are: Men had higher cardiovascular fitness levels than women, with an average level of VO2max of 36.3 ml O2/min/kg for
Full details of the objective measures of physical activity can be found in Chapter 3: Accelerometry in adults, of the HSE 2008 on pages 59 to 88. Included within this chapter is information on the activity
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men and 32.0 ml O2/min/kg for women. In both sexes, the mean VO2max decreased with age. Cardiovascular fitness was lower on average among those who were obese (32.3 ml O2/min/kg among men and 28.1 ml O2/min/kg among women) than among those who were neither overweight nor obese (38.8 ml O2/min/kg and 33.9 ml O2/min/kg respectively). Virtually all participants were deemed able to walk at 3 mph on the flat but 84% of men and 97% of women would require moderate exertion for this activity. Thirty two per cent of men and 60% of women were not fit enough to sustain walking at 3 mph up a 5% incline. Lack of fitness increased with age. Physical fitness was related to selfreported physical activity. Average VO2max decreased, and the proportion classified as unfit increased, as selfreported physical activity level decreased.
4.4 Participation in different activities

4.4.1 Occupational activity
Adults aged 16 to 74 who had worked (paid or voluntary) in the last four weeks were asked about their moderate intensity physical activity during work, as part of the HSE 2008. Respondents were asked about time spent sitting or standing, walking around, climbing stairs or ladders and lifting, carrying or moving heavy loads. Some of the key findings are: Men spent slightly more time than women sitting and/or standing, climbing stairs and/or ladders and carrying or moving heavy loads. Men and women spent similar amounts of time walking around. Twenty four per cent of men and 11% of women reported doing at least 30 minutes of moderate or vigorous activity in total whilst at work each day, thus meeting the government recommendations for physical activity solely from their work. Most men (62%) and women (59%) considered themselves to be very or fairly active at work.
Full details of the physical fitness in adults in 2008 can be found in the Chapter 4: Physical fitness in adults, of the HSE 2008. Details of physical fitness in adults in 1990 can be in the ADNFS report and the key findings are: Seven out of 10 men and 8 out of 10 women fell below their age appropriate activity level. One in 6 people reported having done no activities for 20 minutes or more at a moderate or vigorous level in the previous four weeks.
Self-reported levels of physical activity during work hours are discussed in Chapter 2: Self-reported physical activity in adults, section 2.4.2 on page 33 and Table 2.9 on pages 53 and 54 of the HSE 2008, including age and gender breakdowns of the different types of occupational physical activity.
4.4.2 Non-occupational activity

Participation in different activities, outside of work, was collected for all adults aged over 16, as part of the HSE 2008. Physical
activities were grouped into four main categories: walking, heavy housework, heavy manual/ gardening/ DIY and sports and exercise. Some key findings are: The most common activity for men was sports and exercise (51% had participated in the past four weeks) and the least common was heavy manual/ gardening/ DIY (28% had participated in the past four weeks). The most common activity for women was heavy housework (59% had participated in the past four weeks) whilst the least common was heavy manual/ gardening/ DIY (12% had participated in the past four weeks). On average men had participated in non-occupational physical activity on 13.9 days in the past four weeks, compared with 12.2 days for women.
In 2010, 15% of respondents said they ride a bicycle at least once a week and a further 10% said they did so at least once a month whilst 66% said they use a bicycle less than once a year or never.
Full details of walking and cycling can be found in the complete set of annual NTS tables, charts and maps in the National Travel Survey (NTS) 2010. The Active People Survey 2010/11 monitors participation in 32 sports in England and tracks changes in the recorded levels of participation over time. In this survey participation is defined as the number of adults (aged 16 and over) who have taken part in the sport at moderate intensity for 30 minutes or more at least once in the last week. In 2010/11, the most common sports that people had participated in were swimming (2,809,300 participants), football (2,117,000 participants) and athletics (1,899,400 participants).
Full details of participation in nonoccupational physical activity can be found in Chapter 2: Self-reported physical activity in adults, pages 21 to 58 and Tables 2.7 and 2.8 on pages 49 to 52 of the HSE 2008. The National Travel Survey (NTS) 2010 reports on the frequency of travel by different modes of transport including walking and cycling. Respondents were asked how often they took walks of 20 minutes or more without stopping, for any reason. The NTS also asks respondents about cycling, access to bicycles, and frequency and length of cycle journeys. Some of the key findings from this report are: In 2010, 41% of respondents (aged 2+) said they made walks of 20 minutes or more at least 3 times a week and a further 23% said they did so at least once or twice a week. Twenty per cent of respondents reported that they took walks of at least 20 minutes less than once a year or never.
Further details of the number of people participating in each sport and how this has changed since 2007/08 can be found in the Active People Survey 2010/11. The Taking Part Survey in 2005/068 and 2006/079 included information on the ten most popular activities that adults took part in at least once in the previous 4 weeks. In both 2005/06 and 2006/07, swimming was the most popular activity with 15.7% of respondents in 2005/06 and 14.5% of respondents in 2006/07 having participated in the previous 4 weeks.
Further details can be found in the TPS 2005/06 Chapter 8: Active Sport pages 75 to 83 and TPS 2006/07, section 2.7 on pages 7 and 8.
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4.5 Geographical patterns in physical activity

4.5.1 Physical activity levels by Strategic Health Authority
The HSE 2008 contains information on selfreported physical activity by Strategic Health Authority (SHA) in Chapter 2: Selfreported physical activity in adults, Table 2.2 on page 45. The percentage of adults doing the recommended levels of physical activity varied by SHA, but no particular region stood out.
Figure 4.1 Adults participation in sport 2010/11
England Percentage of adults participating Quartile Classifications: 18.1% to 26.1% (high) 16.5% to <18.1% (middle-high) 14.7% to <16.5% (low-middle) 8.9% to <14.7% (low)
Percentages
4.5.2 Sport and active recreation by Local Authority

Within the Active People Survey 2010/11, information is collected on Adults participation in sport and active recreation at Local Authority (LA) level. Figure 4.1 shows the proportion of adults who participated in moderate intensity activity for 30 minutes at least three times a week, in each LA. Detailed results of activity levels by LA can be found within the Active People Survey 2010/11.
1.The sports participation indicator measures the number of adults (aged 16 and over) participating in at least 30 minutes of sport at moderate intensity at least three times a week. It does not include recreational walking or infrequent recreational cycling but does include cycling if done at least once a week at moderate intensity and for at least 30 minutes. It also includes more intense/strenuous walking activities such as power walking, hill trekking, cliff walking and gorge walking.
Data sources: ONS Boundary Files 2008, The Active People Survey 09/10. Sport England Crown copyright. All rights reserved (100044406) (2011) The Health and Social Care Information Centre. 2011 re-used with the permission of Sport England.
4.5.3 Physical Activity levels in Scotland and Wales

The Scottish Health Survey 201010 contains information on self-reported physical activity in adults in Scotland. The key finding regarding meeting government physical activity recommendations is that in 2010, 39% of adults aged 16 and over reported meeting the governments recommendations for physical activity in Scotland. Forty five per cent of men and 33% of women reported meeting the recommendations. Full details of physical activity in Scotland can be found in the Scottish Health Survey 2010, Chapter 6: Physical Activity. The Welsh Health Survey 201011 contains information on the self-reported physical activity levels of adults in Wales. The key finding regarding meeting government physical activity recommendations is:
In Wales, in 2010, 30% of adults reported meeting the recommended levels of physical activity in the last week. A higher proportion of men than women reported meeting the recommendations (37% and 24% respectively).
more hours than women (44% of men and 39% of women). On average, both men and women spent 2.8 hours watching television per weekday. Men averaged 3.2 hours of watching television on weekend days and women averaged 3.0 hours. Average total sedentary time varied by BMI category. The proportion of women who spent more than four hours per weekday and weekend day increased as BMI category increased, this was also the case for men on weekend days. Accelerometry data for adults shows that in 2008, those who were not overweight or obese spent fewer minutes on average in sedentary time (591 minutes for men, 577 minutes for women) than those who were obese (612 minutes for men, 585 minutes for women).
Further details of physical activity can be found in the Welsh Health Survey 2010, Chapter 4: Health-related lifestyle, section 4.6: Physical activity on page 55 and Table 4.2 on page 68.
4.6 Sedentary time

Sedentary time is at least as important as moderate intensity physical activity as a disease risk factor. Sedentary behaviour is not merely the absence of physical activity; rather it is a class of behaviours that involve low levels of energy expenditure. Sedentary behaviours are associated with increased risk of obesity and cardiovascular disease independently of moderate to vigorous activity levels.12 In England, in 2002, physical inactivity was estimated to cost at least 2 billion and maybe up to 8.2 billion a year and does not include the contribution of physical inactivity to obesity estimated at 2.5 billion annually13. Chapters 2: Self-reported physical activity in adults, and 3: Accelerometry in adults of the HSE 2008 asked adults about the amount of time they spent in sedentary pursuits including time spent watching television, other screen time, reading and other sedentary activities. Some key findings from these chapters are: Average total sedentary time combines both time spent watching the television and other sedentary time. Similar proportions of men and women were sedentary for six or more hours on weekdays (32% and 33% respectively). However, on weekend days, men were more likely to be sedentary for six or
Full details of the sedentary time of adults are available in Chapter 2: Self-reported physical activity in adults, sections 2.4.3 and 2.4.4 and Tables 2.10 and 2.11 of the HSE 2008. Objective measures of sedentary time were collected by the accelerometers and these results are discussed in Chapter 3: Accelerometry in adults, Tables 3.2 to 3.6 of the HSE 2008.
4.7 Knowledge and attitudes towards physical activity

In the Chapter 4: Adult physical activity: knowledge and attitudes, on pages 69 to 106 of the HSE 2007, adults were asked about their perceptions and attitudes to physical activity including adults awareness of recommended physical activity levels, whether respondents believe they are achieving recommended levels and barriers
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to partaking in physical activity. Some key findings from this chapter are: Around a quarter of adults (27% of men and 29% of women) thought they knew the current recommendations for physical activity in 2007. Fewer than 1 in 10 adults specified a level equivalent to the minimum target for physical activity. A high proportion of both men and women aged 16 to 64 perceived themselves to be either very or fairly physically active compared with other people their own age (75% of men and 67% of women). In 2007, women were slightly more likely than men to want to be more physically active than at present (69% and 66% respectively).
Men and women were found to have different barriers to doing more activity. Men were most likely to cite work commitments as a barrier to increasing their physical activity (45%), while lack of leisure time was the barrier most cited by women (37%).
Further information can be found in Chapter 4: Adult physical activity: knowledge and attitudes, of the HSE 2007. This includes differences in attitudes and perception by gender and age (Tables 4.1 to 4.5, 4.8, 4.9, 4.12, 4.13 and 4.16), SHA (Tables 4.6, 4.10 and 4.14) and equivalised household income (Tables 4.7, 4.11 and 4.15).
References
1. At least 5 a week: Evidence on the impact of physical activity and its relationship to health A report from the Chief Medical Officer. The Department of Health, 2004. Available at: www.dh.gov.uk/en/Publicationsandstatistic s/Publications/PublicationsPolicyAndGuida nce/DH_4080994 2. Health Survey for England 2008: Physical Activity and Fitness. The NHS Information Centre, 2009. Available at: www.ic.nhs.uk/pubs/hse08physicalactivity 3. Health Survey for England 2007. The NHS Information Centre, 2008. Available at: www.ic.nhs.uk/pubs/hse07healthylifestyles 4. The Taking Part Survey 2011/12 quarter 2. The Department for Culture, Media and Sport, 2011. Available at: http://www.culture.gov.uk/publications/873 4.aspx 5. The National Travel Survey 2010. The Department for Transport, 2011. Available at: http://www.dft.gov.uk/statistics/releases/nat ional-travel-survey-2010/ 6. The Active People Survey, 2010/11. Sport England. Available at: http://www.sportengland.org/research/activ e_people_survey/aps5.aspx 7. Allied Dunbar National Fitness Survey. Sports Council and Health Education Authority, 1995. Available at: http://www.esds.ac.uk/findingData/snDescr iption.asp?sn=3303 8. Taking Part: The National Survey of Culture, Leisure and Sport, Annual Report 2005/2006.The Department for Culture, Media and Sport, 2007. Available at: http://www.culture.gov.uk/reference_library /publications/3682.aspx 9. Taking Part: The National Survey of Culture, Leisure and Sport, Annual Report 2006/2007.The Department for Culture, Media and Sport, 2008. Available at: http://webarchive.nationalarchives.gov.uk/ +/http://www.culture.gov.uk/reference_libra ry/publications/5396.aspx 10. The Scottish Health Survey 2010, Volume 1: Main Report. The Scottish Government, 2011. Available at: http://www.scotland.gov.uk/News/Releases /2011/09/27102058 11. The Welsh Health Survey, 2010. Welsh Assembly, 2011. Available at: http://wales.gov.uk/topics/statistics/publicat ions/healthsurvey2010/?lang=en 12. Stamatakis E, Hirani V, Rennie K. Moderate-to-vigorous physical activity and sedentary behaviours in relation to body mass index-defined and waist circumference-defined obesity. British Journal of Nutrition, 2009;101:765-773. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18680 630 13. Physical activity and health - facts and figures, Sustrans. Available at: http://www.sustrans.org.uk/what-wedo/active-travel/active-travel-informationresources/physical-activity-and-healthfacts-and-figures
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people should do a minimum of 60 minutes of at least moderate intensity physical activity each day. In the HSE 2008, the summary levels for activity of children and young people are divided into three levels: meets recommendations, some activity and low activity. Meets recommendations, formerly called high in earlier HSE reports, is defined as children doing at least 60 minutes of at least moderate intensity activity on all 7 days in the last week. Some activity, formerly medium activity in previous HSE reports, is defined as 30 to 59 minutes of moderate or greater intensity activity on all 7 days in the last week. Low activity is defined as children who do fewer than 30 minutes of moderate activity on each day, or moderate activity of 60 minutes or more on fewer than 7 days in the last week.
5.1 Introduction
The main source of data used in this chapter is the Health Survey for England (HSE). The HSE gathers information on the physical activity levels of children aged 2 to 15. In the HSE 2008,1 in addition to selfreported physical activity, objective measures of physical activity were also collected using accelerometry data for children aged 4 to 15. The HSE 2008 gathered information on self-reported participation in physical activities excluding the time spent at school. The HSE 2008 is still the most up to date source of information on self-reported and objective measures of physical activity so has been included again in this publication. Other sources of data used in this chapter include the Taking Part Survey (TPS),2 PE and Sport Survey3 and the National Travel Survey.4 The TPS collects data about engagement and non-engagement in culture, leisure and sport, showing how people enjoy their leisure time. The PE and Sport Survey collects information about levels of school sport in schools taking part in the School Sport Partnership Programme in England, while the National Travel Survey is designed to provide a databank of personal travel information for Great Britain. This chapter provides an overview of the published data on physical activity in children and links to other data sources.
5.2.1 Self-reported physical activity

Self-reported physical activity levels in children aged 2 to 15 are given in Chapter 5: Self-reported physical activity in children, pages 117 to 157 of the HSE 2008. Overall, in 2008, a higher proportion of boys (32%) than girls (24%) were classified as meeting the governments recommendations for physical activity. Among girls the proportion meeting the recommendations generally decreased with age, ranging from 35% in girls aged 2 to 12% among those aged 14. There was a less consistent pattern with age among boys. Chapter 5: Self-reported physical activity in children, Tables 5.1 to 5.5 on pages 138 to 140 of the HSE 2008 gives more detailed information on childrens self-reported activity levels including activity levels by
5.2 Meeting physical activity guidelines

At the time the data was collected the Chief Medical Officer (CMO) of England recommended that children and young
Strategic Health Authority (SHA), body mass index (BMI), equivalised household income and Spearhead Primary Care Trust (PCT) status. A discussion of physical activity and obesity is included within Chapter 3 of this report which covers Obesity among Children.
(section 6.4.2, page 164 and Table 6.3), analyses by BMI category (Table 6.6), equivalised household income (Tables 6.4 and 6.8) and Spearhead PCT status (Section 6.5, page 166 and Tables 6.10 and 6.11). This chapter also contains further comparisons of the results observed in the self-reported and objective measures of activity. The Taking Part Survey collects data on participation in culture, leisure and sport. From 2006 the survey was extended to include children aged 11 to 15 and in 2008/09 the sample was further increased to include children aged 5 to 10. In 2010/11, 85% of 5-10 year olds had taken part in sports activities outside of school time in the last four weeks. Meanwhile, 95% of 11-15 year olds have taken part in sporting activities both in and out of school in the last four weeks. In both the 5-10 and 11-15 age groups, boys were more likely to have done sport in the last 4 weeks than girls. A competitive sport topic was introduced in January 2011. In January to March of that year, almost two thirds (64%) of 5-10 year olds played sport at school in organised competitions (such as a sports day). Meanwhile, 44 per cent of 11-15 year olds had participated in competitive sport in this way. For 11-15 year olds, playing sport against others in PE and games lessons (75%) was the most common way of doing competitive sport, whilst being a member of a club that plays sport (32%) was the least common. Full details are presented from pages 14 22 of the 2010/11 Taking Part Statistical Release.
5.2.2 Objective measures of physical activity

Objective measures of physical activity in children aged 4 to 15 along with the methods of collection are given in Chapter 6: Accelerometry in children, pages 159 to 180 of the HSE 2008. Accelerometers were used to independently measure physical activity over a 7 day period by recording frequency, intensity and duration of physical activity in one minute epochs. Based on the results of the accelerometer study, more boys than girls were classified as meeting the governments recommendations for physical activity (33% and 21% respectively). These objective findings are similar to those of the selfreport study. However, the accelerometers showed that there was considerable variation by age. For boys aged 4 to 10, 51% met the government recommendations but only 7% of boys aged 11 to 15 had met these recommendations. For girls the pattern was similar, although fewer met the recommendations in either age group. Among girls aged 4 to 10, 34% had met the recommended target, whereas in this study none of the girls aged 11 to 15 had done so. Full details of the objective measures of physical activity in children are provided in Chapter 6: Accelerometry in children, of the HSE 2008 including information on the activity patterns of children and young people for weekdays and weekend days
Copyright 2012, The Health and Social Care Information Centre. All Rights Reserved
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5.3 Types of physical activity

5.3.1 Travel to / from school
In recent years, travelling to and from school has been recognised as an opportunity for children to achieve part of their recommended daily physical activity. The HSE 2008 included questions on how children travel to and from school. Almost two thirds of children aged 2 to 15 who had attended school, nursery or playgroup in the last week had walked to or from school on at least one day in the last week (63% of boys and 65% of girls). More boys than girls cycled to or from school on at least one day in the last week (5% of boys compared to 2% of girls).
5.3.2 Other types of physical activity

The HSE 2008 asks children about participation in formal sports, for example swimming, football, tennis and gymnastics and informal activities including kicking a ball around, running about and playing active games. Time spent in walking (excluding to and from school) was included as a separate category of activity. Ninety-five per cent of boys and girls had participated in any physical activity in the past week. More girls than boys had participated in walking in the last week (65% and 61% respectively). More boys than girls had participated in formal sports (49% and 38% respectively) and in informal activities (90% of boys and 86% of girls).
Further details are provided in Chapter 5: Self-reported physical activity in children, section 5.4.1 on page 126 and Tables 5.7 to 5.9 on pages 142 and 143 of the HSE 2008. The National Travel Survey (NTS) 2010 presents data on travel to/from school for children aged 5 to 16. This includes information on the number of trips to and from school by walking and cycling per child per year, for the years 1995/1997 to 2010 (Table NTS0613). Figures for 2010 suggest that 41% of 5-16 year olds main method of getting to and from school is walking, while the main method for 33% of this age group is being driven to school in a car / van. Just 2% used a bike to travel to school as their main mode of transport.
Chapter 5: Self-reported physical activity in children, of the HSE 2008 includes full details of the activities children participate in, including information on the number of days and hours of participation and analyses by age, gender (Tables 5.10 to 5.12 on pages 144 to 148), equivalised household income (Table 5.14 on page150) and Spearhead PCT status (Table 5.15 on page 150). The Taking Part Survey 2010/115 includes information on the top 10 sports activities carried out by children. The most popular sports activities carried out by children aged 5 to 10, outside school hours was swimming, diving or lifesaving with 48% participating in the previous four weeks, followed by football (including five-aside) (36%) and cycling or riding a bike (including BMX and mountain biking) (28%).
For children aged 11 to 15 the most popular sports activities participated in the past four weeks both in and out of school were football (including five-aside) (50%), basketball (including minibasketball) (27%) and swimming, diving or lifesaving (27%). A competitive Sport topic was introduced in January 2011. In January to March of that year, 80% of 5-15 year old children reported they had done some form of competitive sport in the last 12 months. Around three quarters (75%) had taken part in competitive sport in school, whilst 41% had taken part outside of school. In January to March 2011, almost a third (30%) of 11-15 year olds belonged to a sports club, making this the most common means of doing competitive sport outside school. Over a fifth (23%) played for a sports team.
taking part in the School Sport Partnership programme in England. In total 21,436 schools and further education (FE) colleges took part in the survey between May and July 2010. This Survey measured the takeup of 3 hours of high-quality PE and out-ofhours school sport in a typical week. This release was last published in September 2010 and is currently discontinued.
5.4.1 Participation in PE and school sport

The key findings from the survey show that in 2009/10, 55% of pupils in years 1-13 of participating schools took part in at least 3 hours of high quality PE and out of hours school sport in a typical week. Among the three types of schools that were surveyed (primary, secondary and special), 64% of pupils in primary schools, 46% of pupils in secondary schools and 64% of pupils in special schools reported participating in at least three hours of high quality PE and out of hours school sport in a typical week.
Further details are provided in Tables 2.2 on page 19 and 2.3 on page 20, and Figures 2.6 on page 21 and 2.8 on page 22 of the 2010/11 Taking Part Survey. The National Travel Survey reports on the frequency of different types of travel including walking and cycling. This report shows that in Great Britain 2010, 68% of children aged 2 to 16, reported walking for 20 minutes or more, at least once a week. Full details are available within the Transport Statistics Bulletin, National Travel Survey 2010.
5.4.2 Time spent on PE and school sport

The PE and Sport Survey covers physical activity both as part of the curriculum and activities that take place outside of school hours, for example school sports clubs. The key findings show that overall; pupils in years 1 to 13 in the schools surveyed spent an average of 117 minutes in a typical week in 2009/10 on curriculum PE. The long term trend shows an increase in the average number of minutes pupils take part in PE each week. In 2004/05 the average number of minutes for Years 1 11 was 107, compared to 123 in 2009/10. For the first time data was collected by gender and showed that slightly more boys (80%) took part in at least 120 minutes of curriculum
5.4 Participation in Physical Education and school sport

The PE and Sport Survey 2009/10 (which followed on from the School sports survey), aimed to collect information about the levels of participation in physical education (PE) and school sport in schools
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PE compared to girls (78%). In Years 1 6 there is no difference between the sexes, but on entry to secondary school a difference emerges. At Year 7 this difference is only two percentage points (89% of girls participate in at least two hours of curriculum PE, compared to 91% of boys), rising gradually to reach a four or five percentage point differential in Years 10, 11, 12 and 13. The PE and Sport Survey 2009/10 includes full details of the amount of time children in partnership schools spend in PE and out of hours school sport (Chapter 3, pages 9 to 22) including gender patterns (Figure 15 page 22), the types of sports children participate in (Chapter 5, pages 32 to 34), participation in intra- and inter-school competitive activities (Chapter 4, pages 23 to 31) and links to other clubs and organisations (Chapter 6, pages 35 to 36).
Among girls, the activity level of parents made relatively little difference to the proportion meeting recommendations, but those who had parents with low activity levels were considerably more likely to be in the low activity category themselves.
Further details of the influence of parental participation in physical activity on childrens physical activity are given in Chapter 5: Self-reported physical activity in children, section 5.3.3, pages 125 and 126 and Table 5.6 on page 141 of the HSE 2008.
5.6 Sedentary behaviour

Sedentary time is at least as important as moderate physical activity as a disease factor. Sedentary behaviour is not merely the absence of physical activity; rather it is a class of behaviours that involve low levels of energy expenditure. The HSE 2008 asked children about the amount of time spent in sedentary pursuits including time spent watching television, other screen time, reading and other sedentary pursuits. In Chapter 5: Self-reported physical activity in children, of the HSE 2008, self-reported sedentary time is presented and the key findings show: The amount of time spent in sedentary pursuits was similar for boys and girls on weekdays (excluding time at school), with both boys and girls spending 3.4 hours in sedentary pursuits. Both boys and girls spent more time in sedentary pursuits on weekend days (4.1 hours for boys and 4.2 hours for girls). The pattern of sedentary behaviour differed with the age of children and
5.5 Parental participation

The HSE 2008 collected information on parental activity levels which allow analysis of childrens physical activity by parental physical activity. Parental physical activity was classified into three categories, as with childrens, though the definitions were different (see Chapter 4 for definitions). The key findings show that: A greater proportion of fathers than mothers reached the then government physical activity recommendations based on self-reported data (46% and 38% respectively). Among boys aged 2 to10, more met the physical activity recommendations for children if their parents did so for adults. Among boys aged 11 to 15 the same pattern was apparent for their fathers activity levels but not for mothers. Similarly, among both age groups, more boys were in the low activity category if their parents were also in this group.
between weekdays and weekend days. On weekdays, there was little variation among younger children, with fewer than 10% of those aged 2 to 9 years being sedentary for six or more hours per day, while the percentage rose steeply after this age. At weekends, the percentage that were sedentary for six or more hours generally increased across all age groups from 8% of boys and girls aged 2 to 40% of boys and 41% of girls aged 15. Full details of the sedentary time of children and young people are available in Chapter 5: Self-reported physical activity in children, section 5.4.3, pages 130 to 132 of the HSE 2008. Details include analyses of sedentary time by Strategic Health Authority (SHA) (Table 5.17), BMI status (Table 5.20), equivalised household income (Table 5.18) and Spearhead PCT status (Table 5.19). Objective measures of sedentary time were collected for children aged 4 to 15 by the accelerometers; these are discussed in Chapter 6: Accelerometry in children on pages 159 to 180 of the HSE 2008.
and a further 8% of boys and 3% of girls overestimated the minimum recommendations. Most children perceive themselves as being either very or fairly physically active compared with children their own age (90% of boys and 84% of girls respectively). Girls were more likely than boys to want to do more physical activity (74% and 61% respectively). When asked about activities they would like to do more of in the future, boys most frequently mentioned ball sports (39%), riding a bike and swimming (both 35%), whereas girls were most likely to mention swimming (47%).
Full details on the behaviour, knowledge and attitudes towards physical activity are provided in Chapter 9: Childrens physical activity, behaviour, knowledge and attitudes, pages 251 to 278 of the HSE 2007.
5.7 Attitudes and perceptions to physical activity

In the HSE 2007,5 (which remains the most up to date source) children aged 11 to 15 were asked about their knowledge and attitudes to physical activity. Information was collected on childrens knowledge of how much physical activity they should do related to recommended physical activity targets, perception of their own physical activity levels and their desire to do more physical activity. The key findings from HSE 2007 showed that: When asked how much physical activity children should do, only one in 10 children aged 11 to 15 suggested that it should be 60 minutes or more each day
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References
1. The Health Survey for England 2008: Physical Activity and Fitness. The NHS Information Centre, 2009. Available at: www.ic.nhs.uk/pubs/hse08physicalactiv ity 2. This Cultural and Sporting Life: The Taking Part 2010/11 Adult and Child Report, Statistical Release, The Department for Culture, Media and Sport, 2011. Available at: http://www.culture.gov.uk/images/resea rch/taking-part-Y6-child-adult-report.pdf 3. The PE and Sport Survey 2009/10. The Department for Children, Schools and Families, 2010. Available at: http://education.gov.uk/publications/sta ndard/publicationDetail/Page1/DFERR032 4. The National Travel Survey 2010. The Department for Transport, 2011. Available at: http://assets.dft.gov.uk/statistics/release s/national-travel-survey-2010/nts201001.pdf 5. The Health Survey for England 2007. The NHS Information Centre, 2008. Available at: www.ic.nhs.uk/pubs/hse07healthylifesty les
Diet
The report of years 1 and 2 combined of the new NDNS rolling programme (April 2008 to March 2010)2 focuses on food consumption and nutrient intakes for adults aged 19 to 64 years and 65 years and over. This is also presented for children aged 18 months to 3 years, 4 to 10 years and 11 to 18 years. Intakes are compared with government recommendations and comparisons with findings from previous surveys are also made. Data on fruit and vegetable consumption among both adults and children are taken from the HSE as this source is used to monitor the Governments 5 a day target, encouraging people to eat at least five portions of fruit and vegetables a day. Data presented in this chapter are taken from the HSE 20075, HSE 20086, HSE 20097 and HSE 2010.8
6.1 Introduction
Poor diet and nutrition are recognised as major contributory risk factors for ill health and premature death. This chapter describes information available about purchases and consumption of food and drink among both adults and children. Most of this information comes from three major national surveys; the Living Costs and Food Survey (LCF), the National Diet and Nutrition Survey (NDNS) and the Health Survey for England (HSE). The LCF survey collects information on the type and quantity of food and drink purchased in households. The LCF survey was previously known as the Expenditure and Food Survey (EFS). It was renamed in 2008 when it became a module of the Integrated Household Survey (IHS). Findings from the survey are published annually in the Family Food report, by the Department for Environment, Food and Rural Affairs (DEFRA), with Family Food 20101 being the most recent edition. The LCF is conducted throughout the year (January to December) across the whole of the UK. The NDNS2 results were published from the first two years (combined) of a new rolling programme of a continuous cross-sectional survey of the food consumption, nutrient intakes and nutritional status of people aged 18 months and older living in private households in the UK. The NDNS involves an interview, a four-day dietary diary and collection of blood and urine samples. The previous NDNS had collected data on consumption for 19 to 64 year olds over a period of seven days in Great Britain which was conducted in 2000/20013. The last NDNS for those aged 4 to 18 years was carried out in 1997.4
6.2 Adults diet

6.2.1 Trends in purchases and expenditure on food and drink
Estimates of expenditure and quantities of food and drink purchased and brought into the household have been collected since the mid 1970s by the National Food Survey (1974 to 2000), the Expenditure and Food Survey (EFS) (2001/02 to 2007) and subsequently the LCF (since 2008). Family Food 2010 presents trends in UK purchases and expenditure on food and drink, based on the LCF. Table 1.1 on page 3 of this report shows quantities of household purchases of food and drink in the UK between 2007 and 2010. Table 1.3 on page 6 shows expenditure on food and drink over the same period. Chapter 5 on pages 51 to 56 presents some analysis on how the rises in food prices in 2010 have
45
affected spending patterns. Some key findings were: Household purchases of fruit fell by 0.9% in 2010 and are now 11.6% lower than 2007. Household purchases of vegetables increased by 0.4% in 2010 but are 2.9% lower than 2007. Since 2009, purchases of fresh fruit fell by 0.8%, fresh green vegetables fell by 4.5% and fruit juices fell by 2.1%. The average weekly expenditure on all household food and drink in 2010 was 27.57 per person (this was 26.75 per person in 2009), after a 3.1% rise in food prices. There have been significant upward trends in household expenditure on eggs, butter, beverages and sugar and preserves.
Britain, for all age groups studied. The analyses did not identify any new nutritional problems in the general population. Chapter 5 on Dietary intakes from the Headline results of the NDNS Years 1 & 2 of the Rolling Programme (2008/2009 2009/2010) show the key findings of consumers diet over a 4 day diary period between February 2008 and March 2010. Table 5.3 shows vegetable, fruit, meat and fish consumption (including from composite dishes). The main findings from the report show that: Adults (aged 19 to 64 years), consumed on average 4.2 portions of fruit and vegetables per day and older adults (aged 65 years and over) consumed 4.4 portions. Thirty per cent of adults and 37% of older adults met the five-a-day recommendation Boys aged 11-18 years, on average, consumed 3.1 portions of fruit and vegetables per day and 13% met the five a day recommendation. Girls in the same age group consumed 2.7 portions per day and 7% met the recommendation. Mean saturated fat intakes for all age groups exceeded the recommended level of no more than 11% of food energy. The mean saturated fat intake for adults aged 19 to 64 years was 12.8% of food energy. Mean intakes of trans fatty acids provided 0.7-0.9% of food energy for all age groups, which was within the recommendation of no more than 2% food energy. Mean intakes of non-milk extrinsic sugars (NMES) exceeded the recommendation of no more than 11% of food energy for children aged 4 to 10 years (14.4% food energy), children aged 11-18 years (15.7% food energy) and adults aged 19 to 64 years (12.6%)
Family Food 2010 also presents some regional analysis of food purchases using a 3 year average. Table 3.4 on page 30 shows purchases of selected food groups by Government Office Region. Some findings were: Household purchases of vegetables (excluding potatoes) were highest in the South West and lowest in the North West (1,241 and 974 grams per person per week respectively). Household purchases of fruit were highest in London and lowest in the North East (1,337 and 944 grams per person per week respectively).
6.2.2 Consumption of food and drink by age and gender

Results from years 1 and 2 (combined) of the rolling NDNS programme showed that diet and nutrient intakes of the UK population were largely similar to findings from previous assessments of diet in Great
61% of adults (aged 19-64) and 53% of older adults (aged 65 years and over) consumed alcohol during the four-day diary. Adults who had consumed alcohol obtained 9% of energy intake from alcohol in the 19 to 64 age group and 6% in the 65 years and over group.
standardised by equivalised household income and Tables 8.5 and 8.6 (pages 150) show the same information by Spearhead status and sex. Some key findings in 2009 were: Higher consumption was also associated with higher income, and vice versa: 32% of men and 37% of women in the highest income quintile had consumed five or more portions in 2009, but only 18% of men and 19% of women in the lowest quintile had done so. The proportion of adults eating five or more portions of fruit and vegetables per day was higher among adults in non-Spearhead Primary Care Trusts (PCTs) (27% of men and 31% of women) than in Spearhead PCTs in 2009 (20% of men and 23% of women).
6.2.3 Fruit and vegetable consumption

The HSE Adult trend tables were updated in 2010 for fruit and vegetable consumption. Fruit and vegetable consumption is measured in portions per day for HSE, based on consumption in the day before the interview. Portions are expressed in everyday units such as whole or half fruit and tablespoons or bowls, to make it easier for participants to recall their consumption accurately. Some key findings in 2010 were: 25% of men and 27% of women consumed the recommended five or more portions of fruit and vegetables daily in 2010 (26% of adults). These results are similar to those reported in 2009, and are slightly lower than in 2006, when 28% of men and 32% of women consumed at least five portions daily. Women continued to be more likely than men to consume five or more portions of fruit and vegetables a day in 2010. Consumption varied with age among both sexes, being lowest among those aged 16-24 (19% of men and 21% of women this age ate five or more portions).
Scotland and Wales carry out their own health surveys. Fruit and vegetable consumption can be found in Section 5.3 on pages 117 to 121 of the Scottish Health Survey 2010.10 Similarly, fruit and vegetable consumption can be found in Section 4.5 on pages 54 of the Welsh Health Survey 2010.11 In 2010, the percentage of adults consuming the recommended five or more portions of fruit and vegetables daily was 22% in Scotland and 35% in Wales. This compares with 26% for England.
6.2.4 Knowledge and attitudes

Chapter 5 on pages 107 to 147 of the HSE 2007 report (this is the most up-to-date source) asked respondents about their knowledge of and attitudes towards diet and healthy eating. Tables 5.7 and 5.8 (pages 133 and 134) present data on knowledge of fruit and vegetable guidelines, Tables 5.10 and 5.11 (pages 136 and 137) show data on perceptions of
More detailed data on consumption of fruit and vegetables was last reported in Chapter 8 on pages 137 to 144 of the HSE 2009 report.9 Tables 8.1 and 8.2 (pages 146 and 147) show daily consumption and types of fruit and vegetables consumed by age and sex, Tables 8.3 and 8.4 (pages 148 and 149) show these data age
47
diet, Tables 5.12 to 5.16 (pages 138 to 143) on attitudes to healthy eating and Table 5.17 (page 144) on barriers to improving diet. Some key findings were: A higher proportion of women (78%) than men (62%) correctly stated that five portions of fruit and vegetables should be consumed per day. The majority of participants believed their own diet to be quite healthy (71% for men and 72% for women). Women were more likely to consider that they had a very healthy diet compared with men (19% and 16% respectively) and less likely to report their diet as being not very healthy/very unhealthy (8% of women and 12% of men). The majority of men and women agreed with the statements Healthy foods are enjoyable (66% of men and 80% of women) and I really care about what I eat (64% of men and 74% women). Few agreed that Healthy eating is just another fad (10% of men and 8% of women.
per person per day. Eating out accounted for an average of 11% of energy intake per person in 2010. There was a small increase (0.2%) in the total intake of sodium in 2010 although levels are still 0.6% lower than in 2007. Eating out accounted for 12% of sodium intakes, broadly in line with eating out as a percentage of total energy intake. Despite a rise of 5.2% in 2010, eating out intake remains 2.5% lower than in 2007. Major contributors to household intake of sodium in 2010 include; non-carcase meat and meat products, bread and other cereals and cereal products.
Family Food 2010 also presents some country and regional analysis of energy intake, using data covering the combined years 2008-2010. Table 3.2 on pages 2627 shows energy and nutrient intakes by country and Table 3.6 shows the same information by Government Office Region. Some findings were: Total energy intake was lowest in England (2,264 kcal per day) compared to Scotland, Wales, and Northern Ireland which had similar intakes (2,357 2,353 and 2,332 kcal per day respectively). Total energy intake was highest in the South West (2,396 kcal per day) and lowest in London (2,171 kcal per day).
6.2.5 Energy and macronutrients from food and drink

Trends in energy and nutrient intake are available from Chapter 2 of Family Food 2010. Key findings are: Based on food purchases, total energy intake per person fell 0.5% in 2010. Although the downward movement since 2007 is not statistically significant there is a clear picture of a longer term downward trend. Total energy intake for 2010 was 2,292 kcal per person per day (2,303 in 2009). Energy from eating out fell sharply between 2006 and 2008 although with rises in 2009 and 2010 there is no evidence of a downward trend. Average energy intake from eating out was 3.8% lower in 2010 than in 2007 at 258 kcal
6.3 Childrens diet

6.3.1 Consumption of food and drink
The new NDNS Rolling Programme covers children as well as adults. The report of years 1 and 2 combined (2008/09-2009/10) focuses on food consumption and nutrient intakes for children aged 18 months to 3
years, 4 to 10 years and 11 to 18 years. Some of the findings include: Consumption of brown, granary and wheatgerm bread, which includes 50:50 breads (bread made from a mixture of white and whole grain flour), was higher in children aged four to 10 years than seen in the previous survey. For children aged four to 18 years there was a fall in the average consumption of other (non-high fibre) breakfast cereals. For children aged 11 to 18 years there was also a fall in the consumption of high fibre breakfast cereals whilst for children aged four to 10 years consumption had risen, meaning there was little change in total breakfast cereal consumption in children aged four to 10 years, but a decrease in children aged 11 to 18 years. A higher percentage of four to 10 year olds were consuming high fibre breakfast cereals than seen in the previous survey. Semi-skimmed milk was the most commonly consumed type of milk for all age groups except those aged 1.5 to three years for whom whole milk was the most commonly consumed type of milk. Average consumption of fruit was highest in children aged 1.5 to three years (102g per day) compared with that for children aged four to 10 years (96g per day) and 11 to 18 years (62g per day). Compared with the last survey of this age group in 1997, consumption of vegetables (excluding potatoes) was higher for children aged four to 10 years. Compared with the last survey of this age group in 1997, average consumption of sugar and chocolate confectionery was reduced from 30g to 18g per day (39% decrease) for
children aged four to 10 years and from 31g to 20g per day (35% decrease) for children aged 11 to 18 years; a lower percentage of children in both age groups were consuming these foods.
6.3.2 Fruit and vegetable consumption

The latest HSE 2010 Child Trend Tables12 (Table 7) shows that between 2009 and 2010, the percentage of 5-15 year old boys consuming 5 or more portions of fruit and vegetables decreased from 21% to 19%. For 5-15 year old girls the corresponding percentages showed a similar decrease from 22% to 20%. Overall, the mean number of portions consumed was 3.2 portions for boys and 3.3 portions for girls in 2010. Further detailed information on the consumption of fruit and vegetables among children aged 5 to 15 years are given in chapter 14 on pages 333 to 348 of volume 1 of the HSE 2008. Tables 14.1 to 14.3 (pages 342 to 345) show daily consumption and types of fruit and vegetables consumed by age and sex, Table 14.4 (page 346) shows daily consumption by Strategic Health Authority (SHA) and Table 14.5 (page 347) by equivalised household income. Some key findings in 2008 were: Fresh fruit was the most commonly eaten item. More girls than boys reported eating fresh fruit the previous day (72% of girls and 68% of boys). The consumption of fresh fruit was related to age, with younger children consuming more fresh fruit than older children. A higher proportion of boys and girls living in the South Central SHA consumed five or more portions of fruit and vegetables per day than children in other regions (25% of boys compared with 15%-23% in other regions and
49
33% of girls compared with 13%-24% in other regions). Boys and girls living in households in the highest income quintile were the most likely to meet the 5 a day recommendations (27% of boys and 30% of girls). There was little variation among those in the lower quintiles (from 16% to 19% of boys and 17% to 20% of girls).
portions of fruit and vegetables should be consumed each day. However, only 22% of boys and 21% of girls could correctly identify what a portion was. More than four in five children regarded their diet as healthy with most saying it was quite healthy (70% of boys and 72% of girls) rather than very healthy (13% of both boys and girls). Only 1% thought that their diet was very unhealthy.
6.3.3 Knowledge and attitudes

Chapter 10 on pages 279 to 308 of the HSE 2007 report (this remains the most upto-date source) asked children aged between 11 and 15 about their knowledge of and attitudes towards diet and healthy eating. Tables 10.6 and 10.7 (page 300) show data on knowledge of fruit and vegetable consumption, Table 10.8 (page 301) on perception of diet, Tables 10.9 to 10.13 (pages 302 to 306) on attitudes to healthy eating and Tables 10.14 and 10.15 (page 307) on factors affecting improvement in diet. Some key findings in 2007 were: Around two in three boys and three in four girls accurately reported that five
The majority of children aged 11-15 agreed that Healthy foods are enjoyable (72% of girls and 64% of boys). There was a more even spread of agreement, disagreement and neutral views about the statement The tastiest foods are the ones that are bad for you.
References
1. Family Food 2010, Department for Environment, Food and Rural Affairs, 2011. Available at: http://www.defra.gov.uk/statistics/foodfar m/food/familyfood/ National Diet Nutrition Survey: headline results from years 1 and 2 (2008/2009 2009/2010), Department of Health. 2011. Available at: http://www.dh.gov.uk/en/Publicationsand statistics/Publications/PublicationsStatisti cs/DH_128166 National Diet and Nutrition Survey: adults aged 19-64 years. Available at: http://www.ons.gov.uk/ons/aboutons/surveys/social-surveys/ourpublications/health-and-care/nationaldiet---nutrition-survey---adults-aged-19to-64-years/index.html National Diet and Nutrition Survey: young people aged 4 to 18 years. The Food Standards Agency, 2000. Available at: http://www.ons.gov.uk/ons/aboutons/surveys/social-surveys/ourpublications/health-and-care/nationaldiet---nutrition-survey---children-aged-4to-18-years/index.html Health Survey for England 2007. The NHS Information Centre, 2008. Available at: www.ic.nhs.uk/pubs/hse07healthylifestyl es 6. Health Survey for England 2008. The NHS Information Centre, 2009. Available at: www.ic.nhs.uk/pubs/hse08physicalactivit y Health Survey for England 2009. The NHS Information Centre, 2010. Available at: www.ic.nhs.uk/pubs/hse09report Health Survey for England 2010. The NHS Information Centre, 2011. Available at: http://www.ic.nhs.uk/pubs/hse10report Health Survey for England 2010 Adult Trend Tables. The NHS Information Centre, 2011. Available at: www.ic.nhs.uk/pubs/hse10trends The Scottish Health Survey 2010, Volume 1: Main Report. Scottish Government, 2011. Available at: http://www.scotland.gov.uk/Publications/ 2011/09/27084018/0 The Welsh Health Survey, 2010. Welsh Government, 2011. Available at: http://wales.gov.uk/topics/statistics/headli nes/health2011/110913/?lang=en Health Survey for England 2010 Child Trend Tables. The NHS Information Centre, 2011. Available at: http://www.ic.nhs.uk/pubs/hse10trends
2.
7.
8.
3.
9.
10. 4.
11.
5.
12.
51
Health outcomes
2010 amid concerns about a raised risk of heart attacks and strokes. This follows the withdrawal of the marketing authorisation for the less prescribed obesity drug Rimonabant in 2009 for similar reasons.
7.1 Introduction
The association between obesity and increased risk of many serious diseases and mortality is well documented and has led to the National Institute for Health and Clinical Excellence (NICE) developing guidelines on identifying and treating obesity.1 This chapter focuses on the health outcomes related to being overweight and obese. Information from the National Audit Office2 (NAO) and a House of Commons Select Committee report,3 is used to establish the broad risk of death and disease associated with obesity. Data from the Health Survey for England 2009 (HSE 2009)4 are used to analyse the relationships between Body Mass Index (BMI) and waist circumference and the prevalence of selected diseases in the population. These data have been analysed for this report and has not been published before. Whist the 2010 HSE has been published the accompanying dataset is not available at the time of this publication. Data on finished admission episodes and finished consultant episodes related to a diagnosis of obesity are presented using the Hospital Episode Statistics (HES) databank5 produced by The NHS Information Centre for health and social care (NHS IC). In addition information on prescription drugs used for the treatment of obesity from the Prescribing Unit at the NHS IC,6 including data on the number of items prescribed and the net ingredient cost of drugs used in the treatment of obesity are also included. European regulators suspended the marketing authorisation for the weight loss drug Sibutramine in early
7.2 Relative risks of diseases and death

Obesity is a major public health problem due to its association with serious chronic diseases such as type 2 diabetes, hypertension (high blood pressure), and hyperlipidaemia (high levels of fats in the blood that can lead to narrowing and blockages of blood vessels), which are major risk factors for cardiovascular disease and cardiovascular related mortality. Obesity is also associated with cancer, disability, reduced quality of life, and can lead to premature death. Figure 7.1 shows the extent to which obesity increases the risks of developing a number of diseases relative to the nonobese population. For example, it is estimated that an obese woman is almost 13 times more likely to develop type 2 diabetes than a woman who is not obese. These relative risks are based on a comprehensive review of international literature carried out by the NAO to provide the best estimates that could be applied to England (see Appendix A for more details). The basis of the estimates varies due to differences in the methodologies of the studies selected, but the table gives a broad indication of the strength of association between obesity and each of the diseases.
Figure 7.1 Relative risk factors for obese people of developing selected diseases, by gender
England Men Type 2 diabetes Hypertension Myocardial infarction Cancer of the colon Angina Gall bladder diseases Ovarian cancer Osteoarthritis Stroke Source: National Audit Office, NAO Copyright 2006. UK National Audit Office 5.2 2.6 1.5 3.0 1.8 1.8 1.9 1.3 Numbers Women 12.7 4.2 3.2 2.7 1.8 1.8 1.7 1.4 1.3
Appendix B. In this section, where obese men and women or obesity is referred to it includes morbidly obese.
7.3.1 Blood pressure

Table 1 from the HSE 2010 Adult Trend Tables7 shows the latest trend information on blood pressure levels by age and gender for 2003-2010. Within this section, the latest information on blood pressure by BMI and waist circumference have been updated using data from HSE 2009 as this is the latest data available. Among adults aged 16 and over, the prevalence of high blood pressure (whether controlled with medication or not) was found to be affected by both increased BMI and raised waist circumference. Table 7.1 shows that overweight men and women were more likely to have high blood pressure than those in the normal weight group (30% compared to 20% in the normal weight group for men and 26% compared to 15% in the normal weight group for women), while obese men and women were most likely to have high blood pressure (51% and 46% respectively). This is also shown in Figure 7.2.
Figure 7.2 High blood pressure by Body Mass Index (BMI) and gender, 2009
England
Men Women
The NAO estimated that in 1998 over 30,000 deaths in England were attributable to obesity, approximately 6% of all deaths in that year. Around 9,000 of these were premature deaths (i.e. occurred before state retirement age). In 2004, research by a House of Commons Select Committee, estimated that 34,100 deaths were attributable to obesity. This equates to 6.8% of all deaths in England.
7.3 Relationships between obesity prevalence and selected diseases

Guidance published by the National Institute for Health and Clinical Excellence (NICE) recommends the use of waist circumference in conjunction with BMI for assessing the health risks associated with being overweight or obese. A raised waist circumference is defined as greater than 102cm in men and greater than 88cm in women. This section looks at the relationship between having an increased BMI and selected diseases and also considers the effect of having a raised waist circumference, using data from HSE 2009. For further information please see
Percentages
60 50 40 30 20 10 0 Normal (BMI 18.5 to less than Overweight (BMI 25 to less than 25) 30)
Source: Health Survey for England 2009. The NHS Information Centre
Obese (BMI 30 or more)
53
Table 7.2 shows that men with a raised waist circumference were more than twice as likely to have high blood pressure as those with a waist circumference of 102cm or less (51% compared with 23%). The pattern was similar for women; 42% of those with a raised waist circumference had high blood pressure, compared with 15% of those with a waist circumference of 88cm or less.
Figure 7.3 Limiting longstanding illness by Body Mass Index (BMI) and gender, 2009
England
Men Women
Percentages
35 30 25 20 15 10 5
7.3.2 Longstanding illness

Table 11 from the HSE 2010 Adult Trend Tables shows the latest trend information on general health, longstanding illness and acute sickness by gender for 1993-2010. Within this section, the latest information on longstanding illness by BMI and waist circumference has been updated using data from HSE 2009 as this is the latest data available. Table 7.3 shows that, in 2009, the prevalence of limiting longstanding illness (whereby a longstanding illness limits the respondents activity in some way) was higher among obese men and women (28% and 33% respectively) than those in the normal weight group (16% and 15% respectively). Men and women who were obese were also more likely to report a non-limiting longstanding illness than men and women in the normal weight group. This is also shown in Figure 7.3.
0 Normal (BMI 18.5 to less than 25) Overweight (BMI 25 to less than 30) Obese (BMI 30 or more)
Source: Health Survey for England 2009. The NHS Information Centre
Table 7.4 shows that both men and women with a raised waist circumference were more likely to report having a limiting longstanding illness than those without a raised waist circumference (29% compared with 18% for men and 33% compared with 17% for women). Table 7.5 shows that neither men nor women who were either overweight or obese score differently on the GHQ12 questionnaire (designed to measure selfassessed general health, acute sickness leading to reduction in recent activity and psychosocial wellbeing) than those men and women in the normal weight group. No recent data has been collected that discusses cardiovascular disease, diabetes and general health and their relationships with BMI and waist circumference but data using HSE 20068 can be found in chapter 7 of Statistics on obesity, physical activity and diet: England, 20099.
7.4 Hospital Episode Statistics

Data on Finished Admission Episodes (FAEs) and Finished Consultant Episodes (FCEs) are available from the Hospital Episode Statistics (HES) databank from The NHS Information Centre. This section presents recorded FAEs in England where there was a primary or secondary diagnosis of obesity and recorded FCEs in England where there was a primary diagnosis of obesity and a main or secondary procedure of bariatric surgery. These data are based on the tenth revision of the International Classification of Diseases (ICD-10).10 The FCE data for bariatric surgery are based on the Office for Population, Censuses and Surveys: Classification of Intervention and Procedures, 4th Revision (OPCS-4) codes.11 The most recent data available are for the financial year 2010/11. HES data is available from 1989-90 onwards. During this time there have been ongoing improvements in data quality and coverage, which particularly affect earlier data years. As well as this, there have been a number of changes to the classifications used within HES records. Changes in NHS practice also need to be borne in mind when analysing time series. This may be particularly relevant for admissions with a primary or secondary diagnosis where some of the increases may be attributable to changes in recording practice.
within the year. In this chapter an FAE is referred to as a hospital admission. Table 7.6 shows that in 2010/11 there were 11,574 hospital admissions with a primary diagnosis of obesity among people of all ages. This is over ten times as high as the number in 2000/01 (1,054) and more than double three years earlier (5,018). Over the period 2000/01 to 2010/11, in almost every year, more than twice as many females were admitted to hospital than males, with a primary diagnosis of obesity (Figure 7.4).
Figure 7.4 Finished Admission Episodes with a primary diagnosis of obesity, by gender, 2000/01 to 2010/11
England
10,000 9,000 8,000 7,000 N u m b er 6,000 5,000 4,000 3,000 2,000 1,000 0 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 Year 2007/08 2008/09 2009/10 2010/11
Numbers
Females
Males
Source: Hospital Episode Statistics, HES. The Information Centre
In 2010/11, the age groups with the highest number of admissions with a primary diagnosis of obesity were those aged 35 to 44 (3,277) and those aged 45 to 54 (3,573). Together these two age groups accounted for more than half of all such admissions (Table 7.7, Figure 7.5).
7.4.1 Finished admission episodes with a diagnosis of obesity

A Finished Admission Episode (FAE) is the first period of inpatient care under one consultant within one healthcare provider. It should be noted that admissions do not represent the number of inpatients, as a person may have more than one admission
55
Figure 7.5 Finished Admission Episodes with a primary diagnosis of obesity, by age, 2010/11
England
4000
Figure 7.6 Finished Admission Episodes with a primary or secondary diagnosis of obesity, by gender, 2000/01 to 2010/11
England
160 140 120
Thousands
Numbers
3500 3000 2500 2000 1500 1000 500 0 Under 16 16-24 25-34 35-44 45-54 55-64 65-74 75 and over
100 80 60 40 20 0 2000/01
Females
Males
2001/02
2002/03
2003/04
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
Among Strategic Health Authorities (SHAs) in 2010/11, over one in every five admissions with a primary diagnosis of obesity occurred in London SHA (2,708), with the next highest number in East Midlands SHA (1,623). North East SHA had the highest rate of admissions per 100,000 of the population (40) and South Central, South West and North West SHA had the lowest (14). As with the national data, more females were admitted to hospital with a primary diagnosis of obesity than males in each of the SHAs. Note that admission figures cannot be used to compare prevalence of obesity between areas as people may travel for treatment and treatment may be concentrated in some areas. Also SHAs may adopt different treatment practices (Table 7.8). In 2010/11, there were 211,783 admissions with a mention of obesity (i.e. a primary or a secondary diagnosis). These data show that obesity is far more likely to be recorded as a secondary than a primary diagnosis. Females are more likely than males to be admitted to hospital with either a primary or secondary diagnosis of obesity with 136,566 female admissions with a mention of obesity compared to 75,190 male admissions (but this gap between genders is not to the same extent as for primary diagnoses only) (Table 7.9, Figure 7.6).
Table 7.10 shows that in 2010/11, adults aged 55 to 64 had the highest number of recorded hospital admissions with either a primary or secondary diagnosis of obesity (43,754), followed by those aged 45 to 54 years (39,258) and 65 to 74 years (36,056). This pattern differs from that for admissions with a primary diagnosis only, where it was shown that the highest number of admissions occurred in those aged 45 to 54. The North West SHA had the largest number of admissions with either a primary or secondary diagnosis of obesity (32,995) and the North East SHA had the highest admission rate (557 per 100,000 population). South Central SHA reported the least number of admissions (10,884) and South East Coast reported the lowest admission rate (256 per 100,000 of the population). The consistency of reporting diagnoses may vary by SHA and needs to be considered when interpreting these data (Table 7.11).
7.4.2 Bariatric surgery

The term bariatric surgery is used to define a group of procedures that can be performed to facilitate weight loss, although these procedures can also be performed for other conditions. It includes stomach stapling, gastric bypasses and sleeve gastrectomy, performed on the stomach and/or intestines to limit the amount of food an individual can consume. Such surgery is
used in the treatment of obesity for people with a BMI above 40, or for those with a BMI between 35 and 40 who have health problems such as type 2 diabetes or heart disease. Table 7.12 shows the number of recorded Finished Consultant Episodes (FCEs) where there was a primary diagnosis of obesity and the main or secondary procedure was recorded as one of codes used to define bariatric surgery for the purpose of this report (see Appendix B for a full list of these procedure codes). An FCE is defined as a period of admitted patient care under one consultant within one healthcare provider. The figures do not represent the number of patients as a person may have more than one episode of care within the same stay in hospital or in different stays in the same year. Surgical procedures are recorded using the Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th Revision (OPCS-4) codes. Operative procedure codes were revised from 2006-07. 2010-11 data uses OPCS 4.6 codes, 2009-10 data uses OPCS 4.5 codes, 2008-09 and 2007-08 data uses OPCS 4.4 codes, 2006-07 data uses OPCS 4.3 codes, data prior to 2006-07 uses OPCS 4.2 codes. Results based on the old coding system cannot be compared with results based on the revised systems so data for 2006/07 to 2010/11 are presented separately from previous years. See Appendix B for further details. There was a year on year increase in the number of recorded FCEs for bariatric surgery from 261 in 2000/01 to 1,038 in 2005/06. Annually the ratio of these recorded FCEs between men and women remained relatively constant with around eight in ten recorded FCEs involving female patients (Table 7.12). Using the new classifications, in 2010/11 there were 8,087 recorded FCEs with a
primary diagnosis of obesity and a main or secondary procedure of bariatric surgery. Females continue to account for the majority of these; in 2010/11 there were 1,771 such recorded FCEs for males and 6,315 for females. London SHA had the highest number of recorded FCEs for bariatric surgery in 2010/11 (1,909), while South Central SHA had the lowest (387). East Midlands SHA had the highest number of FCEs per 100,000 of the population, this value being 32. The SHA with the lowest rate was the North West, with 6 FCEs per 100,000 of the population followed by East of England and South Central SHAs with 9 FCEs per 100,000 of the population. (Table 7.13).
7.5 Prescribing
The two drugs most commonly prescribed for the treatment of obesity by GP practices, in England, were Orlistat (Xenical) and Sibutramine (Reductil). Orlistat is a capsule that prevents the absorption of some fat in the intestine, while Sibutramine works in the brain by altering the chemical messages that control how the person taking it feels and thinks about food. This drug has now been suspended following a European review, as well as the less prescribed drug Rimonabant (Acomplia), in 2009, for similar reasons. In 2010, there were 1.1 million prescription items for drugs for the treatment of obesity. Overall, the number of prescription items in 2010 was over seven times the number in 2000, when there were 157 thousand prescription items for drugs for the treatment of obesity. The Net Ingredient Cost (NIC) is the basic cost of a drug, not taking into account discounts, dispensing costs, fees or prescription charges income. The total NIC for drugs for the treatment of obesity increased from 6.6 million in 2000 to 36.9 million in 2010, reaching its peak
57
in 2007 at 51.6 million. The NIC per item decreased from 42 in 2000 to 33 in 2010 (which showed a slight increase until 2006 where it peaked at 45) (Table 7.14). Almost all (98%) of the total number of prescription items in 2010 for obesity drugs were for Orlistat and the rest (2%) were for Sibutramine (withdrawn during 2010) (Figure 7.7).
Figure 7.7 Number of prescription items for the main drugs used for the treatment of obesity dispensed in primary care, 2000 to 2010
England
1,200 1,000 800 600
Figure 7.8 Number of prescription items dispensed for treatment of obesity per 100,000 of the population, by PCT, 2010
Number of prescription items (000s) Quartile Classifications: 2,960 to 4,340 2,350 to <2,960 1,940 to <2,350 840 to <1,940
Orlistat
Sibutramin
400 200 0 2000
Data sources: ONS Boundary Files 2011, Prescribing Analyses and Cost (PACT) from the Prescription Services a division of the Business Services Authority. Crown copyright. All rights reserved (100044406) (2011) The Health and Social Care Information Centre
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Source: Prescribing Analyses and Cost Tool (PACT) from the Prescription Pricing Division of the Business Services Authority (PPD of the BSA). Copyright 2011, re-used w ith the permission of the Prescription Pricing Devision
Table 7.15 shows prescription data for treatment of obesity by Strategic Health Authority. North West SHA had the greatest number of prescription items in total (195 thousand) and per head of population (2.8 thousand items per 100,000). South Central SHA had the lowest with 52 thousand items, and the lowest per head of population at 1.25 thousand items per 100,000 population. Figure 7.8 shows that the number of prescription items dispensed for the treatment of obesity per 100,000 of the population in each primary care trust (PCT) varies by PCT, with the lowest number of items prescribed being predominantly in the south west.
References
1. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence (NICE), 2006. Available at: http://www.nice.org.uk/guidance/CG4 3 Tackling Obesity in England. National Audit Office, 2001. Available at: www.nao.org.uk/publications/0001/tac kling_obesity_in_england.aspx Obesity. House of Commons Health Committee, 2004. Available at: www.publications.parliament.uk/pa/c m200304/cmselect/cmhealth/23/23.pd f Health Survey for England 2009: The NHS Information Centre, 2010. Available at: www.ic.nhs.uk/pubs/hse09report Hospital Episode Statistics (HES). The NHS Information Centre, 2011. The HES data included in this bulletin are not routinely published, but are available on request. Available at: www.hesonline.org.uk Prescribing Unit. The NHS Information Centre, 2011. The prescription data included in this bulletin are not routinely published but are available on request. Available at: http://www.ic.nhs.uk/statistics-anddata-collections/primarycare/prescriptions Health Survey for England 2010 Trend Tables. The NHS Information Centre, 2011. Available at: www.ic.nhs.uk/pubs/hse10trends 8. Health Survey for England 2006: The NHS Information Centre, 2007. Available at: www.ic.nhs.uk/pubs/hse06cvda ndriskfactors 9. Statistics on obesity, physical activity and diet: England, 2009: The NHS Information Centre, 2009. Available at: www.ic.nhs.uk/pubs/opad09 10. International Classification of Diseases, 10th revision (ICD-10). World Health Organisation. Available at: http://www.who.int/classification s/icd/en/ 11. Office for Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th revision (OPCS-4) codes supplement. Health Protection Agency, 2008. Available at: http://www.hpa.org.uk/web/HPA webFile/HPAweb_C/121550169 0196
2.
3.
4.
5.
6.
7.
59
List of Tables
7.1 7.2 7.3 7.4 7.5 7.6 Blood pressure level by body mass index (BMI) and gender, 2009 Blood pressure level by waist circumference and gender, 2009 Longstanding illness by body mass index (BMI) and gender, 2009 Longstanding illness by waist circumference and gender, 2009 GHQ 12 score by body mass index (BMI) and gender, 2009 Finished Admission Episodes with a primary diagnosis of obesity, by gender, 1999/2000 to 2010/11 Finished Admission Episodes with a primary diagnosis of obesity, by age group, 1999/2000 to 2010/11 Finished Admission Episodes with a primary diagnosis of obesity, by Strategic Health Authority (SHA) of residence and gender, 2010/11 Finished Admission Episodes with a primary or secondary diagnosis of obesity, by gender, 1999/2000 to 2010/11 Finished Admission Episodes with a primary or secondary diagnosis of obesity, by age group, 1999/2000 to 2010/11 Finished Admission Episodes with a primary or secondary diagnosis of obesity, by Strategic Health Authority (SHA) of residence and gender, 2010/11 Finished Consultant Episodes with a primary diagnosis of obesity and a main or secondary procedure of Bariatric Surgery by gender, 1999/2000 to 2010/11 Finished Consultant Episodes with a primary diagnosis of obesity and a main or secondary procedure of Bariatric Surgery, by Strategic Health Authority (SHA), 2010/11 Number of prescription items, net ingredient cost and average net ingredient cost per item of drugs for the treatment of obesity prescribed in Primary Care and dispensed in the community, 2000 to 2010 Number of prescription items of drugs for the treatment of obesity prescribed in Primary Care and dispensed in the community, by Strategic Health Authority (SHA), 2010
7.7
7.8
7.9
7.10
7.11
7.12
7.13
7.14
7.15
Table 7.1 Blood pressure level by body mass index (BMI) and gender, 2009
England Total Men Normotensive untreated Hypertensive controlled Hypertensive uncontrolled Hypertensive untreated All with high blood pressure Women Normotensive untreated Hypertensive controlled Hypertensive uncontrolled Hypertensive untreated All with high blood pressure Unweighted bases Men Women Weighted bases Men Women Underweight Normal Overweight Percentages Obese (including morbidly obese)
68 8 6 18 32
[100] [0] [0] [0] [0]
80 3 4 13 20
70 9 5 16 30
49 12 11 28 51
73 7 7 13 27
[97] [0] [0] [3] [3]
85 4 3 8 15
74 7 6 12 26
54 13 13 20 46
1,240 1,540
10 30
310 550
550 460
290 360
1,365 1,454
23 36
398 545
571 423
289 318
1. See Appendix B for explanations of blood pressure categories. 2. All figures are based on those with a valid blood pressure measurement. 3. BMI categories used for classifying levels of obesity are: underweight = BMI less than 18.5, normal = BMI 18.5 to less than 25, overweight = BMI 25 to less than 30, obese (including morbidly obese) = BMI 30 or more. 4. Total includes those without a valid BMI recorded. 5. Adults aged 16 and over. 6. Hypertensive controlled/uncontrolled are those who take drugs that were prescribed specifically to lower their blood pressure. 7. All with high blood pressure are those who are hypertensive (BP >= 140/90mmHg) or not hypertensive but on treatment that lowers blood pressure. 8. Unweighted bases have been rounded to the nearest 10. 9. [ ] Results in brackets should be treated with caution because of the low base size (below or around 50). Source: Health Survey for England 2009, The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
61
Table 7.2 Blood pressure level by waist circumference and gender, 2009
England Total Men Normotensive untreated Hypertensive controlled Hypertensive uncontrolled Hypertensive untreated All with high blood pressure Women Normotensive untreated Hypertensive controlled Hypertensive uncontrolled Hypertensive untreated All with high blood pressure Unweighted bases Men Women Weighted bases Men Women Non raised waist circumference Percentages Raised waist circumference
68 8 6 18 32
77 5 4 14 23
49 15 10 26 51
73 7 7 13 27
85 4 3 8 15
58 12 12 19 42
1,240 1,540
770 830
450 680
1,365 1,454
911 823
434 607
1. See Appendix B for explanations of blood pressure categories. 2. All figures are based on those with a valid blood pressure measurement. 3. A raised waist circumference is defined as greater than 102cm in men and greater than 88cm in women. 4. Total includes those without a valid waist circumference recorded. 5. Adults aged 16 and over. 6. Hypertensive controlled/uncontrolled are those who take drugs that were prescribed specifically to lower their blood pressure. 7. All with high blood pressure are those who are hypertensive (BP >= 140/90mmHg) or not hypertensive but on treatment that lowers blood pressure. 8. Unweighted bases have been rounded to the nearest 10. Source: Health Survey for England 2009,The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
Table 7.3 Longstanding illness by body mass index (BMI) and gender, 2009
England Total Men Limiting Longstanding Illness Non limiting Longstanding Illness No Longstanding Illness Women Limiting Longstanding Illness Non limiting Longstanding Illness No Longstanding Illness Unweighted bases Men Women Weighted bases Men Women Underweight Normal Overweight Percentages Obese (including morbidly obese)
22 20 59
[23] [15] [63]
16 14 70
19 20 61
28 27 45
23 19 57
[21] [11] [68]
15 16 69
22 22 56
33 24 43
2,110 2,540
30 50
520 830
840 710
450 540
2,341 2,442
45 51
657 835
898 671
453 488
1. BMI categories used for classifying levels of obesity are: underweight = BMI less than 18.5, normal = BMI 18.5 to less than 25, overweight = BMI 25 to less than 30, obese (including morbidly obese) = BMI 30 or more. 2. Total includes those without a valid BMI recorded. 3. Adults aged 16 and over. 4. Unweighted bases have been rounded to the nearest 10. 5. [ ] Results in brackets should be treated with caution because of the low base size (below or around 50). Source: Health Survey for England 2009, The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
63
Table 7.4 Longstanding illness by waist circumference and gender, 2009

England Total Men Limiting Longstanding Illness Non limiting Longstanding Illness No Longstanding Illness Women Limiting Longstanding Illness Non limiting Longstanding Illness No Longstanding Illness Unweighted bases Men Women Weighted bases Men Women Non raised waist circumference Percentages Raised waist circumference
22 20 59
18 18 64
29 22 48
23 19 57
17 17 65
33 22 45
2,110 2,540
910 920
520 800
2,341 2,442
1,104 920
510 722
1. A raised waist circumference is defined as greater than 102cm in men and greater than 88cm in women. 2. Total includes those without a valid waist circumference recorded. 3. Adults aged 16 and over. 4. Unweighted bases have been rounded to the nearest 10. Source: Health Survey for England 2009, The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
Table 7.5 GHQ12 score by body mass index (BMI) and gender, 2009
England Total Men score 0 score 1-3 score 4+ Women score 0 score 1-3 score 4+ Unweighted bases Men Women Weighted bases Men Women Underweight Normal Overweight Percentages Obese (including morbidly obese)
58 27 15
[44] [35] [21]
57 28 15
59 26 14
58 28 14
53 29 18
[43] [39] [18]
59 25 16
53 31 16
50 29 21
1,980 2,400
30 40
510 810
820 680
440 520
2,181 2,305
45 49
626 812
872 646
445 472
1. See Appendix B for explanation of GHQ12. 2. All figures are based on those with a valid GHQ12 score. 3. BMI categories used for classifying levels of obesity are: underweight = BMI less than 18, normal = BMI 18 to less than 25, overweight = BMI 25 to less than 30, obese (including morbidly obese) = BMI 30 or more. 4. Total includes those without a valid BMI recorded. 5. Adults aged 16 and over. 6. Unweighted bases have been rounded to the nearest 10. 7. [ ] Results in brackets should be treated with caution because of the low base size (below or around 50). Source: Health Survey for England 2009, The NHS Information Centre. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
65
Table 7.6 Finished Admission Episodes with a primary diagnosis of obesity, by gender, 2000/01 to 2010/11
England
Total 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 1,054 1,019 1,275 1,711 2,035 2,564 3,862 5,018 7,988 10,571 11,574 Males 309 284 427 498 589 746 1,047 1,405 2,077 2,495 2,919 Numbers Females 741 731 848 1,213 1,442 1,786 2,807 3,613 5,910 8,074 8,654
1. A finished admission episode (FAE) is the first period of inpatient care under one consultant within one healthcare provider. FAEs are counted against the year in which the admission episode finishes. Admissions do not represent the number of inpatients, as a person may have more than one admission within the year. 2. The primary diagnosis is the first of up to 20 (14 from 2002-03 to 2006-07 and 7 prior to 2002-03) diagnosis fields in the Hospital Episode Statistics (HES) data set and provides the main reason why the patient was admitted to hospital. 3. ICD-10 Codes: E66 - Obesity. 4. Figures have not been adjusted for shortfalls in data. 5. Counts include people resident in English Strategic Health Authorites (SHAs) only, including admissions where the SHA of residence was England but not further specified and excludes admissions where the SHA of residence was unknown. 6. Total includes admissions where the gender was unknown. 7. HES data is available from 1989-90 onwards. During this time there have been ongoing improvements in data quality and coverage, which particularly affect earlier data years. As well as this, there have been a number of changes to the classifications used within HES records. Changes have also been made to the organisation of the NHS. These need to be considered when interpreting the accuracy and validity of time series analyses. Source: Hospital Episode Statistics (HES), The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
Table 7.7 Finished Admission Episodes with a primary diagnosis of obesity, by age group, 2000/01 to 2010/11
England Total 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 1,054 1,019 1,275 1,711 2,035 2,564 3,862 5,018 7,988 10,571 11,574 Under 16 226 237 400 579 547 583 656 747 775 632 525 16-24 45 39 65 67 107 96 184 228 322 361 375 25-34 147 134 136 174 287 341 461 564 1,013 1,348 1,425 35-44 255 240 289 391 487 637 1,069 1,469 2,359 3,132 3,277 45-54 214 199 216 273 364 554 872 1,198 2,133 3,076 3,573 55-64 96 97 94 151 174 258 459 598 1,099 1,555 1,820 65-74 56 48 52 52 36 72 118 157 221 378 456 Numbers 75 and over 14 21 23 24 32 20 43 53 63 87 115
1. A finished admission episode (FAE) is the first period of inpatient care under one consultant within one healthcare provider. FAEs are counted against the year in which the admission episode finishes. Admissions do not represent the number of inpatients, as a person may have more than one admission within the year. 2. The primary diagnosis is the first of up to 20 (14 from 2002-03 to 2006-07 and 7 prior to 2002-03) diagnosis fields in the Hospital Episode Statistics (HES) data set and provides the main reason why the patient was admitted to hospital. 3. ICD-10 Codes: E66 - Obesity. 4. Figures have not been adjusted for shortfalls in data. 5. Counts include people resident in English Strategic Health Authorites (SHAs) only, including admissions where the SHA of residence was England but not further specified and excludes admissions where the SHA of residence was unknown. 6. Total includes admissions where the age was unknown. 7. HES data is available from 1989-90 onwards. During this time there have been ongoing improvements in data quality and coverage, which particularly affect earlier data years. As well as this, there have been a number of changes to the classifications used within HES records. Changes have also been made to the organisation of the NHS. These need to be considered when interpreting the accuracy and validity of time series analyses. Source: Hospital Episode Statistics (HES), The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
67
Table 7.8 Finished Admission Episodes with a primary diagnosis of obesity, by Strategic Health Authority (SHA) of residence and gender, 2010/11
England Admissions Total Male England Q30 Q31 Q32 Q33 Q34 Q35 Q36 Q37 Q38 Q39 E18000001 E18000002 E18000003 E18000004 E18000005 E18000006 E18000007 E18000008 E18000009 E18000010 North East North West Yorkshire and the Humber East Midlands West Midlands East of England London South East Coast South Central South West 11,574 1,052 955 1,165 1,623 903 864 2,708 978 571 754 2,919 218 287 306 342 243 324 580 249 184 186 Female 8,654 834 668 859 1,281 660 540 2,128 728 387 568 Numbers Admissions per 100,000 of population Total Male Female 22 40 14 22 36 17 15 35 22 14 14 11 17 8 12 15 9 11 15 12 9 7 33 63 19 32 56 24 18 54 32 19 21
1. A finished admission episode (FAE) is the first period of inpatient care under one consultant within one healthcare provider. FAEs are counted against the year in which the admission episode finishes. Admissions do not represent the number of inpatients, as a person may have more than one admission within the year. 2. The primary diagnosis is the first of up to 20 (14 from 2002-03 to 2006-07 and 7 prior to 2002-03) diagnosis fields in the Hospital Episode Statistics (HES) data set and provides the main reason why the patient was admitted to hospital. 3. ICD-10 Codes: E66 - Obesity. 4. Figures have not been adjusted for shortfalls in data. 5. Counts include people resident in English Strategic Health Authorites (SHAs) only, including admissions where the SHA of residence was England but not further specified and excludes admissions where the SHA of residence was unknown. 6. Office for National Statistics (ONS) estimated resident population mid-2010 figures have been used to calculate admissions per 100,000 http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-231847 7. Totals include admissions where the gender was unknown. Source: Hospital Episode Statistics (HES), The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
Table 7.9 Finished Admission Episodes with a primary or secondary diagnosis of obesity, by gender, 2000/01 to 2010/11
England Total 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 22,878 23,777 29,237 33,546 40,741 52,019 67,211 80,914 102,987 142,219 211,783 Male 8,938 9,448 12,068 13,804 16,590 21,432 27,791 32,080 39,524 52,517 75,190 Numbers Female 13,924 14,320 17,168 19,736 24,145 30,552 39,411 48,829 63,457 89,657 136,566
1. A finished admission episode (FAE) is the first period of inpatient care under one consultant within one healthcare provider. FAEs are counted against the year in which the admission episode finishes. Admissions do not represent the number of inpatients, as a person may have more than one admission within the year. 2. The primary diagnosis is the first of up to 20 (14 from 2002/03 to 2006/07 and 7 prior to 2002/03) diagnosis fields in the Hospital Episode Statistics (HES) data set and provides the main reason why the patient was admitted to hospital. As well as the primary diagnosis, there are up to 19 (13 from 2002/03 to 2006/07 and 6 prior to 2002/03) secondary diagnosis fields in Hospital Episode Statistics (HES) that show other diagnoses relevant to the episode of care. These figures represent the number of episodes where the diagnosis was recorded in any of the 20 primary and secondary diagnosis fields in the record. Each episode is only counted once in each count, even if the diagnosis is recorded in more than one diagnosis field of the record. 3. ICD-10 Codes: E66 - Obesity. 4. Figures have not been adjusted for shortfalls in data. 5. Counts include people resident in English Strategic Health Authorites (SHAs) only, including admissions where the SHA of residence was England but not further specified and excludes admissions where the SHA of residence was unknown. 6. Total includes admissions where the gender was unknown. 7. The quality and coverage of HES data have improved over time. These improvements in information submitted by the NHS have been particularly marked in the earlier years and need to be borne in mind when analysing time series. Some of the increase in figures for later years (particularly 2006-07 onwards) may be due to the improvement in the coverage of independent sector activity. Changes in NHS practice also need to be borne in mind when analysing time series. This may be particularly relevant for admissions with a primary or secondary diagnosis where some of the increases may be attributable to changes in recording practice. Further years data may be required to aid interpretation of these statistics.
Source: Hospital Episode Statistics (HES), The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
69
Table 7.10 Finished Admission Episodes with a primary or secondary diagnosis of obesity, by age group, 2000/01 to 2010/11
England Total 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 22,878 23,777 29,237 33,546 40,741 52,019 67,211 80,914 102,987 142,219 211,783 Under 16 781 856 1,117 1,355 1,506 1,727 1,896 2,104 2,229 2,400 2,762 16 to 24 654 715 912 1,026 1,457 1,717 2,316 3,169 4,326 6,609 12,042 25 to 34 2,142 2,129 2,288 2,449 3,449 4,252 5,319 7,218 9,899 15,490 26,965 35 to 44 3,522 3,512 4,371 4,845 5,953 7,401 9,961 12,101 15,508 21,344 30,606 45 to 54 4,656 4,878 5,661 6,452 7,424 9,858 12,922 15,683 19,971 27,641 39,258 55 to 64 4,877 5,217 6,721 7,790 9,086 12,146 15,882 18,489 23,136 30,884 43,754 65 to74 4,009 4,226 5,391 6,432 7,813 10,056 12,571 14,496 18,234 24,294 36,056 Numbers 75 and over 2,190 2,222 2,738 3,175 4,036 4,840 6,296 7,512 9,531 13,399 20,056
1. A finished admission episode (FAE) is the first period of inpatient care under one consultant within one healthcare provider. FAEs are counted against the year in which the admission episode finishes. Admissions do not represent the number of inpatients, as a person may have more than one admission within the year. 2. The primary diagnosis is the first of up to 20 (14 from 2002/03 to 2006/07 and 7 prior to 2002/03) diagnosis fields in the Hospital Episode Statistics (HES) data set and provides the main reason why the patient was admitted to hospital. As well as the primary diagnosis, there are up to 19 (13 from 2002/03 to 2006/07 and 6 prior to 2002/03) secondary diagnosis fields in Hospital Episode Statistics (HES) that show other diagnoses relevant to the episode of care. These figures represent the number of episodes where the diagnosis was recorded in any of the 20 primary and secondary diagnosis fields in the record. Each episode is only counted once in each count, even if the diagnosis is recorded in more than one diagnosis field of the record. 3. ICD-10 Codes: E66 - Obesity. 4. Figures have not been adjusted for shortfalls in data. 5. Counts include people resident in English Strategic Health Authorites (SHAs) only, including admissions where the SHA of residence was England but not further specified and excludes admissions where the SHA of residence was unknown. 6. Total includes admissions where the age was unknown. 7.The quality and coverage of HES data have improved over time. These improvements in information submitted by the NHS have been particularly marked in the earlier years and need to be borne in mind when analysing time series. Some of the increase in figures for later years (particularly 2006-07 onwards) may be due to the improvement in the coverage of independent sector activity. Changes in NHS practice also need to be borne in mind when analysing time series. This may be particularly relevant for admissions with a primary or secondary diagnosis where some of the increases may be attributable to changes in recording practice. Further years data may be required to aid interpretation of these statistics. Source: Hospital Episode Statistics (HES), The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
Table 7.11 Finished Admission Episodes with a primary or secondary diagnosis of obesity, by Strategic Health Authority (SHA) of residence and gender, 2010/11
England Total England Q30 Q31 Q32 Q33 Q34 Q35 Q36 Q37 Q38 Q39 E18000001 E18000002 E18000003 E18000004 E18000005 E18000006 E18000007 E18000008 E18000009 E18000010 North East North West Yorkshire and the Humber East Midlands West Midlands East of England London South East Coast South Central South West 211,783 14,523 32,995 23,883 21,060 25,453 27,476 23,902 11,237 10,884 20,322 Admissions Male 75,190 5,482 12,139 8,207 6,398 7,907 10,762 8,959 4,382 3,742 7,191 Female 136,566 9,038 20,856 15,676 14,662 17,543 16,712 14,939 6,841 7,142 13,130 Numbers Admissions per 100,000 of population 7 Total Male Female 405 557 476 451 470 467 471 305 256 263 385 292 429 355 314 289 295 374 230 205 183 278 516 681 593 584 647 633 566 380 304 342 489
1. A finished admission episode (FAE) is the first period of inpatient care under one consultant within one healthcare provider. FAEs are counted against the year in which the admission episode finishes. Admissions do not represent the number of inpatients, as a person may have more than one admission 2. The primary diagnosis is the first of up to 20 (14 from 2002/03 to 2006/07 and 7 prior to 2002/03) diagnosis fields in the Hospital Episode Statistics (HES) data set and provides the main reason why the patient was admitted to hospital. As well as the primary diagnosis, there are up to 19 (13 from 2002/03 to 2006/07 and 6 prior to 2002/03) secondary diagnosis fields in Hospital Episode Statistics (HES) that show other diagnoses relevant to the episode of care. These figures represent the number of episodes where the diagnosis was recorded in any of the 20 primary and secondary diagnosis fields in the record. Each episode is only counted once in each count, even if the diagnosis is recorded in more than one diagnosis field of the record. 3. ICD-10 Codes: E66 - Obesity. 4. Figures have not been adjusted for shortfalls in data. 5. Counts include people resident in English Strategic Health Authorites (SHAs) only, including admissions where the SHA of residence was England but not further specified and excludes admissions where the SHA of residence was unknown. 6. Office for National Statistics (ONS) estimated resident population mid-2010 figures have been used to calculate admissions per 100,000 population. Information on ONS population data is available at: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-231847 7. Totals include admissions where the gender was unknown. 8. The quality and coverage of HES data have improved over time. These improvements in information submitted by the NHS have been particularly marked in the earlier years and need to be borne in mind when analysing time series. Some of the increase in figures for later years (particularly 2006-07 onwards) may be due to the improvement in the coverage of independent sector activity. Changes in NHS practice also need to be borne in mind when analysing time series. This may be particularly relevant for admissions with a primary or secondary diagnosis where some of the increases may be attributable to changes in recording practice. Further years data may be required to aid interpretation of these statistics. Source: Hospital Episode Statistics (HES), The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
71
Table 7.12 Finished Consultant Episodes with a primary diagnosis of obesity and a main or secondary procedure of 'Bariatric Surgery' by gender, 2000/01 to 2010/11
England Total OPCS-4.2 procedure codes 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 (OPCS-4.3 procedure codes) 2007/08 (OPCS-4.4 procedure codes) 2008/09 (OPCS-4.4 procedure codes) 2009/10 (OPCS-4.5 procedure codes) 2010/11 (OPCS-4.6 procedure codes) Male Numbers Female
261 281 345 474 744 1,038 1,951 2,724 4,221 7,214 8,087
46 38 65 96 137 200 381 598 969 1,450 1,771
215 241 280 378 603 808 1,562 2,126 3,251 5,762 6,315
1. A finished consultant episode (FCE) is a continuous period of admitted patient care under one consultant within one healthcare provider. FCEs are counted against the year in which they end. Figures do not represent the number of different patients, as a person may have more than one episode of care within the same stay in hospital or in different stays in the same year. 2. The primary diagnosis is the first of up to 20 (14 from 2002-03 to 2006-07 and 7 prior to 2002-03) diagnosis fields in the Hospital Episode Statistics (HES) data set and provides the main reason why the patient was admitted to hospital. 3. ICD-10 Codes: E66 - Obesity. 4. These figures represent the number of episodes where the procedure (or intervention) was recorded in any of the 24 (12 from 2002/03 to 2006/07 and 4 prior to 2002/03) operative procedure fields in a Hospital Episode Statistics (HES) record. A record is only included once in each count, even if the procedure is recorded in more than one operative procedure field of the record. Please note that more procedures are carried out than episodes with a main or secondary procedure. For example, patients under going a cataract operation would tend to have at least two procedures removal of the faulty lens and the fitting of a new one counted in a single episode. 5. The term 'bariatric surgery' is often used to define a group of procedures that can be performed to facilitate weight loss although these procedures can be performed for conditions other than weight loss. It includes stomach stapling, gastric bypasses and sleeve gastrectomy. The procedures for tables 7.12 and 7.13 show the defined range of procedures when a corresponding main diagnosis of Obesity (ICD10-E66) is also present. Definition of codes can be found in Appendix B. 6. All OPCS-4.2, OPCS-4.3, OPCS-4.4, OPCS-4.5 and OPCS-4.6 procedure codes used to define bariatric surgery are described in Appendix B. 7. Figures have not been adjusted for shortfalls in data. 8. Counts include people resident in English Strategic Health Authorites (SHAs) only, including admissions where the SHA of residence was England but not further specified and excludes admissions where the SHA of residence was unknown. 9. Total includes episodes where the gender was unknown. 10. The quality and coverage of HES data have improved over time. These improvements in information submitted by the NHS have been particularly marked in the earlier years and need to be borne in mind when analysing time series. Some of the increase in figures for later years (particularly 2006-07 onwards) may be due to the improvement in the coverage of independent sector activity. Changes in NHS practice also need to be borne in mind when analysing time series. 11. Figures are based on decisions as to which operative procedures constituted 'Bariatric Surgery' at that time. Changes to the figures over time need to be interpreted in the context of improvements in data quality and coverage (particularly in earlier years). In particular, improvements in how 'Bariatric surgery' is coded, with the change of codes in various versions of OPCS, means that had the previous years been based on the latest coding advice, figures would have been slightly different and affects earlier years more. 12. Hospital coding for bariatric surgery was updated in 2009/10 so that it is now possible to identify how many bariatric procedures were for maintenance of an existing gastric band. Nationally, of the 8,087 bariatric procedures in 2010/11, 1,444 of these were for maintenance. Source: Hospital Episode Statistics (HES), The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
Table 7.13 Finished Consultant Episodes with a primary diagnosis of obesity and a main or secondary procedure of 'Bariatric Surgery' by Strategic Health Authority (SHA), 2010/11
England Finished Consultant Episodes Total Male England Q30 Q31 Q32 Q33 Q34 Q35 Q36 Q37 Q38 Q39 E18000001 E18000002 E18000003 E18000004 E18000005 E18000006 E18000007 E18000008 E18000009 E18000010 North East North West Yorkshire and the Humber East Midlands West Midlands East of England London South East Coast South Central South West 8,087 549 447 837 1,426 635 505 1,909 775 387 616 1,771 112 111 210 275 153 170 335 172 103 130 Numbers Finished Consultant Episodes per 100,000 of population Total Male Female 15 21 6 16 32 12 9 24 18 9 12 7 9 3 8 12 6 6 9 8 5 5 24 33 10 23 51 17 11 40 27 14 18
Female 6,315 437 336 627 1,151 482 335 1,574 602 284 486
1. A finished consultant episode (FCE) is a continuous period of admitted patient care under one consultant within one healthcare provider. FCEs are counted against the year in which they end. Figures do not represent the number of different patients, as a person may have more than one episode of care within the same stay in hospital or in different stays in the same year. 2. The primary diagnosis is the first of up to 20 (14 from 2002-03 to 2006-07 and 7 prior to 2002-03) diagnosis fields in the Hospital Episode Statistics (HES) data set and provides the main reason why the patient was admitted to hospital. 3. ICD-10 Codes: E66 - Obesity. 4. These figures represent the number of episodes where the procedure (or intervention) was recorded in any of the 24 (12 from 2002/03 to 2006/07 and 4 prior to 2002/03) operative procedure fields in a Hospital Episode Statistics (HES) record. A record is only included once in each count, even if the procedure is recorded in more than one operative procedure field of the record. Please note that more procedures are carried out than episodes with a main or secondary procedure. For example, patients under going a cataract operation would tend to have at least two procedures removal of the faulty lens and the fitting of a new one counted in a single episode. 5. The term 'bariatric surgery' is often used to define a group of procedures that can be performed to facilitate weight loss although these procedures can be performed for conditions other than weight loss. It includes stomach stapling, gastric bypasses and sleeve gastrectomy. The procedures for tables 7.12 and 7.13 show the defined range of procedures when a corresponding main diagnosis of Obesity (ICD10-E66) is also present. Definition of codes can be found in Appendix B. 6. All OPCS-4.5 procedure codes used to define bariatric surgery are described in Appendix B. 7. Figures have not been adjusted for shortfalls in data. 8. Counts include people resident in English Strategic Health Authorites (SHA) only, including admissions where the SHA of residence was England but not further specified and excludes admissions where the SHA of residence was unknown. 9. Office for National Statistics (ONS estimated resident population mid-2010 figures have been used to calculate FCEs per 100,000 population. Information on ONS population data is available at: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-231847 10. Totals include episodes where the gender was unknown. 11. The quality and coverage of HES data have improved over time. These improvements in information submitted by the NHS have been particularly marked in the earlier years and need to be borne in mind when analysing time series. Some of the increase in figures for later years (particularly 2006-07 onwards) may be due to the improvement in the coverage of independent sector activity. Changes in NHS practice also need to be borne in mind when analysing time series. Source: Hospital Episode Statistics (HES), The NHS Information Centre for health and social care. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
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Table 7.14 Number of prescription items, net ingredient cost and average net ingredient cost per item of drugs for the treatment of obesity prescribed in Primary Care and dispensed in the community, 2000 to 2010
England Thousands /
2000 Prescription Items (thousands) Orlistat 156 Sibutramine Rimonabant Total 157 Net Ingredient Cost ( 000) Orlistat 6,573 Sibutramine Rimonabant Total 6,613
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
415 53 469
540 196 737
484 203 688
492 208 699
645 226 871
774 263 23 1,060
827 294 112 1,233
848 325 106 1,278
1,080 370 1,450
1,087 22 0 1,109
17,575 2,030 19,659
23,401 7,752 31,203
21,036 8,458 29,532
21,391 9,314 30,706
27,020 10,984 38,004
32,476 13,654 1,411 47,541
32,047 13,093 6,440 51,580
29,980 9,595 5,237 44,812
36,769 10,024 46,793
36,297 595 1 36,892
Net Ingredient Cost per item () Orlistat 42 42 43 43 44 42 42 39 35 34 Sibutramine 38 39 42 45 49 52 45 30 27 Rimonabant 62 58 50 Total 42 42 42 43 44 44 45 42 35 32 1. Prescriptions are written on a prescription form known as a FP10. Each single item written on the form is counted as a prescription item. 2. Net Ingredient Cost (NIC) is the basic cost of a drug. It does not take account of discounts, dispensing costs, fees or prescription charge income.
33 27 53 33
3. This information was obtained from the Prescribing Analysis and Cost Tool (PACT) system, which covers prescriptions prescribed by GPs, nurses, pharmacists and others in England and dispensed in the community in the UK. Prescriptions written in hospitals /clinics that are dispensed in the community, prescriptions dispensed in hospitals, dental prescribing and private prescriptions are not included in PACT data. 4. Prescriptions written in England but dispensed outside England are included. 5. Rimonabant was only available on prescription from July 2006, therefore figures for Rimonbant in 2006 only reflect six months worth of data. 6. On 16th January 2009, the European Commission issued a decision to withdraw the marketing authorisation for Rimonabant (Acomplia) following an assessment of the benefits and risks of taking this medicine. 7. Up until 2007 'total' included other drugs that may be used to treat obesity which include Mazindol, Phentermine and Diethylpropion Hydrochloride. 8. On 21st January 2010, the European Medicines Agency (EMA) released a statement advising the suspension of sibutramine following a study which showed that there was an increased risk of non-fatal heart attacks and strokes outweighing the benefits of this weight loss drug. Therefore, data on Sibutramine will be limited for 2010. Source: Prescribing Analyses and Cost (PACT) from the Prescription Pricing Division of the NHS Business Services Authority (PPD of the NHS BSA). The NHS Information Centre. Copyright 2012, re-used with the permission of the Prescription Pricing Division. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
Table 7.15 Number of prescription items of drugs for the treatment of obesity prescribed in Primary Care and dispensed in the community, by Strategic Health Authority (SHA), 2010
England Prescription Items (thousands) Total Orlistat England North East SHA North West SHA Yorkshire and the Humber SHA East Midlands SHA West Midlands SHA East of England SHA London SHA South East Coast South Central South West SHA 1,109 71 195 136 100 126 104 161 77 52 87 1,087 70 191 133 98 123 101 158 76 50 85 p (thousands) per 100,000 population Total Orlistat 2.12 2.73 2.81 2.56 2.23 2.30 1.78 2.05 1.76 1.25 1.64 2.08 2.69 2.75 2.51 2.19 2.26 1.73 2.02 1.72 1.22 1.61
1. Prescriptions are written on a prescription form known as a FP10. Each single item written on the form is counted as a prescription item. 2. This information was obtained from the Prescribing Analysis and Cost Tool (PACT) system, which covers prescriptions prescribed by GPs, nurses, pharmacists and others in England and dispensed in the community in the UK. Prescriptions written in hospitals /clinics that are dispensed in the community, prescriptions dispensed in hospitals, dental prescribing and private prescriptions are not included in PACT data. 3. For data at Strategic Health Authority (SHA) level, prescriptions written by a prescriber located in a particular SHA but dispensed outside that SHA will be included in the SHA in which the prescriber is based. 4. Prescriptions written in England but dispensed outside England are included. 5. Office for National Statistics (ONS) estimated resident population mid-2010 figures have been used to calculate prescription items per 100,000 population. Information on ONS population data is available at: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-213645 6. The 'Total' column includes Sibutramine which is not shown separately due to limited data for 2010 and may not equal the sum of the individual drugs due to rounding. 7. The England figures include an unidentified Doctors element (where it is not possible for the Prescription Pricing Division of the Business Service Authority to allocate to a SHA). 8. On 21st January 2010, the European Medicines Agency (EMA) released a statement advising the suspension of sibutramine following a study which showed that there was an increased risk of non-fatal heart attacks and strokes outweighing the benefits of this weight loss drug. Therefore, data on Sibutramine will be limited for 2010. Source: Prescribing Analyses and Cost (PACT) from the Prescription Pricing Division of the NHS Business Services Authority (PPD of the NHS BSA). The NHS Information Centre. Copyright 2012, re-used with the permission of the Prescription Pricing Division. Copyright 2012. The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved.
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Appendix A: Key sources

Active People Survey Allied Dunbar National Fitness Survey Foresight Tackling Obesities: Future Choices Project report Health Survey for England Hospital Episode Statistics Living Costs and Food Survey Low Income Diet and Nutrition Survey National Diet and Nutrition Survey National Travel Survey Organisation for Economic Co-operation and Development (OECD) Health Data 2009 Prescription Pricing Division Quality Outcomes Framework School Meals Research Project School Sport Survey PE and Sport Survey Tackling obesity in England Taking Part Survey
Active People Survey

The Active People Survey (APS) is the largest ever survey of sport and active recreation to be undertaken in Europe. It is a telephone survey of England (aged 16 and over) and provides statistics on participation in sport and active recreation for all 354 Local Authorities (LA) in England (a minimum of 1,000 interviews were completed in every LA in England). The APS, conducted by Ipsos MORI on behalf of Sport England, started on the 15th October 2005 and was completed on 16th October 2006. The sample was evenly divided over each month and spread across the whole year for each LA to ensure the results are not biased by variations associated with different seasons. Due to the success of the Active People Survey 2005/06, Sport England repeated the survey and plan to run it as a continuous survey. The latest APS started in the middle of October 2009 and ran for twelve months until mid October 2010. Headline results were published in December 2010. The primary objective of the APS is to measure levels of participation in sport and active recreation and its contribution to improving the health of the nation. Sport and active recreation includes walking and cycling for recreation in addition to more traditional formal and informal sports. When measuring sports participation the survey were concerned with not only the type of activity but also the frequency, intensity and duration. Data from the APS is described in Chapter 4 (Physical activity among adults). The latest report, Active People Survey 2010/11 Headline results. Available at:
Copyright 2012, The Health and Social Care Information Centre. All Rights Reserved. 76
http://www.sportengland.org/research/active_people_survey/aps5.aspx
Allied Dunbar National Fitness Survey

The survey was designed to measure the activity and fitness levels of the adult population (aged 16 and over) in England. A representative sample of 6,000 adults was selected at random throughout the country. The fieldwork was carried out between February and November 1990. A total of 4,316 people completed the home interview stage - a response rate of 75%. Seventy per cent of those interviewed took part in a physical appraisal with 62% attending for tests at a specially equipped mobile laboratory and 8%, primarily the elderly and infirm, being tested on a recurred set of measurements in their homes. Many aspects of behaviour, attitudes and beliefs were measured in the home interview. These included: Levels of participation in sport and active recreation, current and past, including access to facilities and barriers to participation; Physical activity at work, in housework, DIY and gardening and in moving about, that is walking, cycling and stair-climbing; Other lifestyle and health-related behaviour, including smoking, alcohol and dietary habits; Current health status and history of illness; Sports-related injuries; Knowledge about exercise and attitudes towards physical activity, fitness and health; Psychological variables including well-being, social support, stress and anxiety.
Information on the Allied Dunbar National Fitness Survey can be found in Chapter 4 (Physical activity among adults). Allied Dunbar National Fitness Survey. Available at: http://www.esds.ac.uk/findingData/snDescription.asp?sn=3303
Foresight Tackling Obesities: Future Choices Project report

One of the Foresight programmes based in the Government Office for Science. The report considers how society might deliver a sustainable response to obesity in the UK over the next 40 years. One objective of the project was to analyse how future levels of obesity might change and to identify the most effective future responses. The report presents key messages and implications for the UK. These are based on an extensive analysis of a wide range of evidence, including several commissioned evidence reviews, a systems analysis of the primary determinants of obesity, scenarios of possible futures and a quantitative model of future trends in obesity and associated diseases. To achieve this aim Foresight commissioned a model which utilises the dataset of the Health Survey for England from 1994 to 2004 and employs extrapolation and microsimulation techniques to predict the distribution of people across various BMI categories, to 2050. The report also models current and future costs of obesity and obesity related diseases to the NHS. Foresight used the 2002 Health Select Committees findings and uses 1 billion as the baseline for obesity attributable healthcare costs in the modeling exercise. The model used forecasted costs solely on the basis of anticipated additional morbidity arising from the increasing prevalence of obesity. Factors other than BMI, including costs of disease were fixed at current levels.
Data used from this report are presented in Chapters 2 and 3 (Obesity among adults and children). Tackling Obesities: Future Choices 2nd Edition Modelling Future Trends in Obesity and Their Impact on Health. Foresight, Government Office for Science, 2007. Available at: http://www.bis.gov.uk/assets/bispartners/foresight/docs/obesity/17.pdf
Health Survey for England

The Health Survey for England (HSE) is an annual survey, monitoring the health of the population which is currently commissioned by The NHS Information Centre (the NHS IC), and before April 2005 was commissioned by the Department of Health. The HSE has been designed and carried out since 1994 by the Joint Health Surveys Unit of the National Centre for Social Research (NatCen) and the Department of Epidemiology and Public Health at the Royal Free and University College Medical School (UCL). All surveys have covered the adult population aged 16 and over living in private households in England. Since 1995, the surveys have also covered children aged two to 15 living in households selected for the survey, and since 2001 infants aged under two have been included as well as older children. Trend tables are also published each year updating key trends on a number of health areas. Each survey in the series includes core questions and measurements such as blood pressure, anthropometric measurements and analysis of saliva and urine samples, as well as modules of questions on specific issues that vary from year to year. In recent years, the core sample has also been augmented by an additional boosted sample from a specific population subgroup, such as minority ethnic groups, older people or, as in 2006, 2007 and 2008, children. This statistical report mainly uses data from HSE 2008, except for where updates to data are available in the 2010 report. The primary focus of the HSE 2008 report was physical activity and fitness. The report investigated associated lifestyle factors such as diet, smoking and drinking, and also assessed the immediate impact of the smoking ban in public places introduced in England in July 2007 as a secondary focus. In 1999, the survey concentrated on the health of adults in six minority ethnic groups: Black Caribbean, Indian, Pakistani, Bangladeshi, Chinese and Irish. In 2004, the survey once again investigated the health of minority ethnic groups; the category of Black African was added to the six groups in the 1999 survey. Some information from the HSE 04 is included in Chapter 2 (Obesity among adults). This report contains data and information from different HSE years. This is to provide the most current information for the general population that was available at the time of publishing. Where possible, data has been used from the HSE 2010, however there are some restrictions to this. For further details of the HSE data used please see Appendix B (Technical notes). Non-response weighting was introduced to the HSE in 2003, and has been used in all subsequent years. Both weighted and unweighted bases are given in each table. The unweighted bases show the number of participants involved. The weighted bases show the relative sizes of the various sample elements after weighting, reflecting their proportions in the English population, so that data from different columns can be combined in their correct proportions. The absolute size of the weighted bases has no particular significance, since they have been scaled to the achieved sample size.
Since 1995, childrens data each year have been weighted to adjust for the probability of selection, since a maximum of two children are selected in each household. This ensures that children from larger households are not under-represented. Since 2003, non-response weighting has also been applied in addition to selection weighting. Trend tables in this publication present figures from 2003 onwards (the first year where non-response weighting was applied) with and without non-response weighting. Data are shown in two rows or columns, one showing unweighted results and the other weighted results. For tables showing trends in childrens data, results for years up to 2002 are based on selection weighting only, and results for 2003 to 2006 are based on selection and non-response weighting. A full discussion of the effects of non-response weighting can be found in the 2003 HSE report, Volume 3, Methodology and Documentation. In the commentary in this report, where comparisons are made between 2008 figures and earlier years, weighted figures for 2008 are referred to since these are considered the most accurate estimate of prevalence. As weighted figures are not available for years before 2003, it is not possible to use weighted figures for earlier years and so the comparison is made with unweighted figures. Data from the HSE are used in Chapters 2, 3, 4, 5, 6 and 7. The Health Survey for England 2008: Physical Activity and Fitness. Available at: Main report: www.ic.nhs.uk/pubs/hse08physicalactivity Trend tables: www.ic.nhs.uk/pubs/hse08trends Health Survey for England 2010: Respiratory Health. Available at: Main report: www.ic.nhs.uk/pubs/hse10report
Trend tables: www.ic.nhs.uk/pubs/hse10trends
The Health Survey for England is a National Statistic.
Hospital Episode Statistics

NHS hospital Finished Admission Episodes (FAEs) in England have been recorded using Hospital Episode Statistics (HES) since April 1987. HES aims to collect a detailed record for each 'episode' of admitted patient care delivered in England by NHS hospitals or delivered in the independent sector but commissioned by the NHS. HES data is presented in financial years, from April to March. A Finished Admission Episodes (FAE) is the first period of in-patient care under one consultant within one healthcare provider. The figures do not represent the number of in-patients, as a person may have more than one admission within the year.
Data from HES used in the report show Finished Admission Episodes with a primary diagnosis or secondary diagnosis of obesity. Within HES, diagnoses are recorded using International Classification of Diseases (ICD) codes. From the financial year beginning April 1995 onwards these were classified using the tenth revision of ICD (ICD-10). Details of ICD-10 codes used are included in Tables 7.6 to 7.13. The primary diagnosis is defined as the main condition treated or investigated during the relevant episode of healthcare. HES data used in Table 7.12 and 7.13 show the number of Finished Consultant Episodes (FCEs) for bariatric surgery. The term bariatric surgery is often used to define a group of procedures that can be performed to facilitate weight loss although these procedures can be performed for conditions other than weight loss. It includes stomach stapling, gastric bypasses and sleeve gastrectomy. An FCE is a period of care under one consultant and patients may experience more than one FCE in a single hospital admission. The figures do not represent the number of patients, as a person may have more than one episode of care within the year or more than one episode of care within a visit to hospital. Bariatric surgery procedures identified using a primary diagnosis of obesity and a main or secondary procedure code for bariatric surgery. Within HES, procedures and interventions are recorded using the Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th Revision (OPCS-4) codes. OPCS-4.2 were used to identify bariatric surgery procedure codes between the years 1996/97 to 2005/06 and OPCS-4.3 codes were used for 2006/07, OPCS-4.4 codes were used for 2007/08 and 2008/09, OPCS-4.5 codes were used for 2009/10 and OPCS-4.6 codes were used for 2010/11, however there were no changes to the codes used to define bariatric surgery between OPCS-4.3 and OPCS-4.4. Details of the OPCS-4.6 codes used are included in Appendix B. The main procedure is usually the most resource intensive procedure performed during the episode. HES data are shown in Chapter 7 (Health outcomes).
Living Costs and Food Survey (LCF), formerly Expenditure and Food Survey (EFS)
The LCF collects information on the type and quantity of food and drink purchased in households. The LCF was previously known as the Expenditure and Food Survey (EFS). It was renamed in 2008 when it became a module of the Integrated Household Survey (IHS). The Expenditure and Food Survey (EFS) was created in 2001 to replace the National Food Survey (NFS) and the Family Expenditure Survey (FES). The EFS provides data on spending and food purchases since the 1950s. Each household member over the age of seven kept a diary of all their expenditure and quantities of purchased food and drink over a two week period. Historical estimates of household purchases between 1974 and 2000 have been adjusted to align with the level of estimates from the FES in 2000. Whilst estimates of household consumption from the NFS have been adjusted, a break in the series between 2000 and 2001 remains and should be borne in mind when interpreting reported changes before and after this period. The aligned estimates are generally higher than the original ones and indicate that the scaling has partially corrected for under-reporting in the NFS. Under-reporting may be lower in the EFS because it does not focus on consumption but on expenditure across the board and is largely based on till receipts.
Reliable estimates on food and drink eaten out from the EFS start in 2001/02, less reliable estimates are available from the NFS going back to 1994. LFC is the data source for two publications, Family Food, published by the Department for Environment, Food and Rural Affairs and Family Spending, published by the Office for National Statistics. Chapter 6 (Diet) of this report presents data published in Family Food using the LFC. Throughout the chapter figures used prior to 2001/02 are adjusted NFS estimates. The adjustments brought the results of the NFS into line with the EFS, and tended to increase estimates of food and drink purchases. The largest adjustments were for confectionery, alcoholic drinks, beverages and sugar and preserves. Adjustments for eggs and carcase meat resulted in reduced NFS estimates. Details of the adjustments to the NFS estimates can be found in Family Food 2002/03. In 2005/06 significant revisions were made affecting estimates from 2001/02 to 2004/05. The revisions introduce estimates of free food into both eating out and household food and quantity and nutrient content for a range of unspecified food purchases which are estimated based on averages of other food purchases recorded in the survey. Examples of free food estimates now included in the survey are meals on wheels, free welfare milk in the home, free milk, fruit and vegetables provided by schools, free meals provided by schools and employers, food purchased for business that is paid for by employer and buffet meals where items are not specified (such as Indian, Chinese, salad bar etc). In 2006 the survey moved from a financial year to a calendar year basis in preparation for its integration to the Integrated Household Survey in January 2008. As a consequence there is an overlap of results, data collected between January 2006 and March 2006 are included in the 2005/06 results and the 2006 results. Where the report looks at 3 year averages and 4 year trends this duplication of data has been removed. As this survey collects information on purchases, consumption is approximated using a wastage estimate. Purchases may differ from actual food consumption for a number of reasons e.g. food may be discarded during preparation, food maybe left on the plate at the end of a meal or food may become inedible before it can be consumed and is thrown away. When average intakes are compared with reference nutrient intakes, a figure of 10% is used for wastage on all types of food and drink. Trends in energy and nutrient content of the purchases are based on a database of nutrient profiles for different types of food which are kept up to date by the Food Standards Agency. Data from the latest Family Food and LCF can be found in Chapter 6 (Diet). Expenditure and Food Survey. Available at http://www.esds.ac.uk/government/efs/ Family Food 2010, Department for Environment, Food and Rural Affairs, 2011. Available at: http://www.defra.gov.uk/statistics/foodfarm/food/familyfood/ Family Spending. Available at: http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=361
Low Income Diet and Nutrition Survey

As the National Diet and Nutrition Survey (also described in this appendix) provided evidence to suggest that differences in food consumption exist between lower and higher socioeconomic groups, the Low Income Diet and Nutrition Survey (LIDNS) was conducted between 2003 and 2005 focusing specifically on people from the low income population in the United Kingdom. This survey provides a comprehensive picture of food consumption and nutritional status of a nationally representative sample living in low income and materially deprived households. It also assessed numerous socioeconomic, environmental, behavioural and attitudinal factors, and lifestyle and health characteristics which relate to food consumption, nutritional status and nutrition-related health. The purpose of the survey was to provide an evidence base that would contribute to the development of food policy, which in turn would help to reduce health inequalities.
Screening questionnaire
A score-based screening questionnaire was devised specifically for LIDNS to provide a useful and discriminating measure of low income and material deprivation. This included a series of questions on use of cars/vans, receipt of incapacity benefit, income support or job seekers allowance, housing and council tax benefits and then further questions on weekly net income for those who have a borderline score.
Dietary Interview
From all households that were screened in as eligible for the survey, two respondents were randomly selected to take part, either one adult (aged 19 and over) and one child (aged 2-18) or two adults (in households with no children). Both respondents as well as the households main food provider (if they were not one of the selected respondents) had an extensive face-to-face computer assisted personal interview. Information about the 24 hour dietary recall process was then given and the first 24h recall was completed.
Repeat 24 hour dietary recall

An interviewer visited the household on a total of four randomly selected non-consecutive days (including where possible a weekend day) over a ten day period to conduct the 24 hour dietary recall interviews. The 24 hour recall method used was the triple pass method, which gives respondents three opportunities to think through what they ate and drank over the previous 24 hour period. Respondents height and weight measurements were recorded during the second visit.
Nurse visit
All individuals completing three or four dietary recalls were eligible for the second part of the survey, which consisted of a visit from a qualified nurse. The nurse collected details of any prescribed medications and non-prescribed dietary supplements and took further measurements, including blood pressure, waist and hip measurements and where consented to, a blood sample. Data from the LIDNS can be found in Chapter 6 (Diet) The latest Low Income Diet and Nutrition Survey. Available at: http://www.food.gov.uk/science/dietarysurveys/lidnsbranch/
National Diet and Nutrition Survey (NDNS)

The National Diet and Nutrition Survey (NDNS) programme aims to provide a comprehensive picture of the dietary habits and nutritional status of the population of the Britain. In its original form the NDNS was a series of cross-sectional surveys covering the whole population from age 1 years upwards, split into four different population age groups: children aged 1 to 4 years (fieldwork 1992/93), young people aged 4 to 18 years (1997), adults aged 19 to 64 years (2000/01) and people 65 years and over (1994/95). Following a review of the Food Standards Agencys dietary survey programme in 2002/03 the NDNS has now moved to a rolling programme in which the survey will run continuously with fieldwork every year, (which started in 2008) covering a UK representative sample of both adults and children. This will strengthen the ability to track changes over time and give flexibility to respond more rapidly to changing data requirements Data from the NDNS are essential for underpinning a wide range of the Food Standards Agencys work to protect consumer safety and promote healthy diets. The survey provides detailed data on foods consumed by individuals and nutrient intakes with additional information on nutritional status (derived from analysis of blood samples), physical measurements and lifestyle habits such as smoking, drinking and physical activity.
The components of the survey

The survey includes various components (described below) in order to obtain the wide range of information required. Respondents may choose to participate in some components but not in others. The components of the most recent NDNS of adults aged 19-64 years are described below.
Dietary interview
Initially a face-to-face dietary interview was carried out with the household member selected to take part in the survey (the respondent), to provide information about their eating and drinking habits, their socio-demographic circumstances (e.g. age and marital status) and the socio-demographic circumstances of their household (e.g. benefit status).
Seven-day weighed intake dietary record

Respondents were also invited to complete a dietary record for seven days. This involved weighing and recording all food and drink consumed both at home and away from home, including medicines taken by mouth and drinks of water. The dietary record collected detailed information in order to look at the range of food consumption and nutrient intake within the population. Food and nutrient intake data could also be related to physical activity and various nutritional status and health measures.
Other components
These included a 24-hour urine collection (used to estimate salt intake); physical measurements (BMI, blood pressure and waist and hip circumferences); a seven-day physical activity record (to allow an investigation of the relationships between dietary intakes, body composition and physical activity levels); and a blood sample (which was analysed for a range of nutritional status indicators which reflect the levels of certain nutrients available for use in the body).
The information from the dietary record was linked to a nutrient databank and nutrient intakes were calculated from the quantities of foods consumed. No attempt has been made to adjust the nutrient intakes presented here to take account of underreporting. Data from the NDNS can be found in Chapter 6 (Diet). National Diet Nutrition Survey: headline results from years 1 and 2 (2008/2009 2009/2010), Department of Health. 2011. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_128166 The National Diet and Nutrition Survey, available at: http://www.food.gov.uk/science/dietarysurveys/ndnsdocuments/
Issues associated with reporting food consumption in dietary surveys

Mis-reporting of food consumption in dietary surveys, generally under-reporting, is known to be a problem in dietary surveys worldwide. Under-reporting can cause biased low estimates of intake as respondents under-report their actual intake or modify their diet during the recording period. The level of under-reporting needs to be borne in mind when interpreting findings from dietary surveys, for example in comparing intakes with recommendations. Analysis of data from the NDNS adults 2000/01 indicated that energy intake could be under-reported by about 25%. It is not possible to ascertain whether under-reporting was higher in this survey than in the 1986/87 survey because there was no assessment of physical activity or energy expenditure in the earlier survey. Doubly labelled water studies suggest similar levels of under-reporting for other age groups except for preschool children where levels were lower. There is evidence that under-reporting is selective fatty, sugary and snack foods and alcohol are more likely to be under-reported than are other foods such as fruit and vegetables. However the level of under-reporting for specific macro and micronutrients is not known. The National Diet and Nutrition Survey is an official statistic.
National Travel Survey

The National Travel Survey (NTS) is a survey on personal travel. It provides the Department for Transport, Local Government and the Regions (DTLR) with data to answer a variety of policy and transport research questions. The 2010 NTS is the latest in a series of household surveys designed to provide a databank of personal travel information for Great Britain. It is part of a continuous survey that began in July 1988, following ad hoc surveys since the mid-1960s. The survey is designed to identify long-term trends and is not suitable for monitoring short-term trends. NTS respondents keep a travel diary of their trips within Great Britain over a seven day period. Travel details provided by respondents include trip purpose, method of travel, time of day and trip length. The households also provided personal information, such as their age, gender, working status and driving licence holding, and details of the cars available for their use. In order to minimise the burden of completing the diaries respondents include walks of under one mile on the seventh day only, but all tables in this publication include data on short walks (over 50 yards) grossed up for the full seven day period.
Data from NTS are used in Chapter 4 and 5 (Physical activity among adults and children). The National Travel Survey 2010. The Department for Transport, 2011. Available at: http://assets.dft.gov.uk/statistics/releases/national-travel-survey-2010/nts2010-01.pdf This is a National Statistic.
Organisation for Economic Co-operation and Development (OECD) Health Data 2011 Frequently Requested Data
Released during November 2011, this report offers the most comprehensive source of comparable statistics on health and health systems across OECD countries. It is an essential tool for health researchers and policy advisors in governments, the private sector and the academic community, to carry out comparative analyses and draw lessons from international comparisons of diverse health care systems. Data from this report can be found in Chapter 2 (Obesity among adults). Health at a Glance 2011. Organisation for Economic Co-operation and Development, 2011. Available at: http://www.oecd.org/dataoecd/6/28/49105858.pdf Definitions. Sources and Methods can be found at: http://www.oecd.org/document/30/0,3746,en_2649_33929_12968734_1_1_1_1,00.html
Prescription Pricing Division

Prescription statistics in this report are for calendar years. All prescription statistics in this report are based on information systems at the NHS Business Services Authority Prescription Pricing Division (NHSBSA (PPD)). The system used is the Prescription Analysis and Cost Tool (PACT). This system is based on an analysis of all prescriptions dispensed in the community, i.e. by community pharmacists and appliance contractors, dispensing doctors, and prescriptions submitted by doctors for items personally administered. Each item written on the prescription form (FP10) is counted a single prescription item regardless of the quantity prescribed. Therefore differences in prescribing practices between GPs are not reflected in this data. The counts include items that are prescribed by GPs, nurses, pharmacists and others in England and then subsequently dispensed in the community. Therefore prescriptions that are written but not actually dispensed to the patient (or their representative) are not counted. Prescriptions written in hospitals or clinics that are dispensed in the community, prescriptions dispensed in hospitals, dental prescribing and private prescriptions are also not included. Data from the Prescription Pricing Division can be found in Chapter 7 (Health outcomes).
Quality and Outcomes Framework

The Quality and Outcomes Framework (QOF) was introduced as part of the new General Medical Services (GMS) contract on 1 April 2004. It is a voluntary annual reward and incentive programme for all GP surgeries in England, detailing practice achievement results. The QOF contains four main components, known as domains. Each domain consists of a set of measures of achievement, known as indicators, against which practices score points according to their level of achievement QOF is measured by QMAS, a national IT system developed by NHS Connecting for Health (CfH). It is not a comprehensive source of data on quality of care in general practice, but it is potentially a rich and valuable source of such information, providing the limitations of the data are acknowledged. The Prescribing Support Unit (PSU), part of The NHS Information Centre, works on behalf of the Department of Health and in collaboration with CfH to obtain extracts from QMAS to support the publication of QOF information. QMAS captures the number of patients on the clinical register for each practice. The number of patients on the clinical registers can be used to calculate measures of disease prevalence expressing the number of patients on each register as a percentage of the number of patients on each practice lists. Data from the QMAS database can be found in Chapter 2 (Obesity among adults). Quality and Outcomes Framework Information. Available at: http://www.ic.nhs.uk/statistics-and-data-collections/audits-and-performance/the-quality-andoutcomes-framework This is an official statistic.
School Meals Research Project

In 2001 National Nutritional Standards were reintroduced to set out the frequency with which school caterers must provide items from the main food groups. The Department for Education and Skills (DfES) and the Food Standards Agency (FSA) commissioned a survey in 2003 to assess compliance with the standards and to measure food consumption in school among secondary school pupils. The survey was conducted in a nationally representative sample of 79 secondary schools across England providing information about catering practise and food provisions at lunchtime and information about the food selections and nutrient intake of 5,695 secondary school pupils aged 11 to 18. This document is referred to in Chapter 6 on Diet. School Meals in Secondary Schools in England. Available at: http://www.food.gov.uk/science/dietarysurveys/primaryschoolmeals
School Sport Survey

The Department for Education (DfE, formerly Department for Children, Schools and Families (DCSF)) commissioned Target Nutrient Specifications (TNS), an independent research company, to conduct the fifth and final annual survey of school sport in England covering the academic year
2007/08. The survey aimed to collect information about levels of participation in physical education (PE) and school sport in partnership schools. In total, 21,631 schools within school sport partnerships took part in the survey between May 2008 and July 2008. The 2007/08 survey reported on what over 6 million school children are doing in terms of physical activity. The survey is the largest of its kind in Europe. School sports partnerships bring primary, special and secondary schools together in a network benefiting from extra staff and funding to increase sports opportunities for pupils. At the time of the 2007/08 survey 90% of pupils in schools within the School Sport Partnership programme participated in at least two hours of high quality PE and out of hours school sport in a typical week. This compared to 86% in 2006/07, 80% in 2005/06, 62% in 2003/04 and the estimated position of 25% in 2002. The 2007/08 School Sport Survey. Available at: http://publications.dcsf.gov.uk/default.aspx?PageFunction=productdetails&PageMode=publications& ProductId=DCSF-RW063&
PE and Sport Survey

In 2008/09 TNS-BMRB (formerly TNS), an independent research company, was commissioned to conduct a further survey of school sport and to provide a consistent dataset to help understand further progress that has been made within partnership schools. The latest 2009/10 survey has continued in its aims to collect information from all partnership schools in the mainstream sector in England and from all Further Education (FE) colleges. Information was collected on the proportion of pupils receiving 2 hours of curriculum PE and the proportion of pupils participating in at least 3 hours of PE and school sport. Data from the School Sport Survey can be found in Chapter 5 (Physical activity among children). The PE and School Sport Survey 2009/10 is available at: http://www.education.gov.uk/publications/RSG/publicationDetail/Page1/DFE-RR032 This is an official statistic.
Tackling obesity in England

In 2001, the National Audit Office (NAO) produced this report which among other subjects, estimated the cost of treating obesity. Costs of obesity were estimated by taking a prevalence-based, cost of illness approach based on extensive literature review and using published data. The cost of treating obesity covers the costs of GP consultations related to obesity, hospital admissions and outpatient attendances and drugs prescribed to help obese patients lose weight. The most recent published data on incidence of these events in England was multiplied by unit costs to calculate a total cost. Prescription costs for obesity were taken from Prescription Cost Analyses reports for England. The cost of treating the consequences of obesity covered the cost of treating diseases such as coronary heart disease which can be directly attributed to obesity. The cost of treating these diseases was estimated by calculating the relevant population risk proportion. A systematic review of literature was undertaken to establish for each disease, the best data available on the proportion of that
disease in the population that was attributable to obesity. This proportion was defined by the relative risk of developing the associated diseases for individuals with obesity compared to the risk for nonobese individuals. To establish the cost of treating associated diseases in 1998, data on GP consultation rates, hospital inpatient admissions and hospital outpatient attendances were obtained. These were multiplied by unit costs to derive an estimate of the NHS treatment costs for each disease. Prescription costs were taken from Prescription Cost Analyses reports for England. These cost estimates were then applied to the data on relative risk and age and sex specific prevalence of obesity from the HSE to give an estimate of the cost of treating the consequences of obesity. It is recognised that the direct costs of treating obesity, estimated as 9.5 million in 1998 is probably an under-estimate because the main component of this cost, GP consultations, was based on data from 1991-92 since which obesity prevalence has increased, and no data were available for consultations with practice nurses and dieticians in primary care. Also, the cost of treating the consequences of obesity is likely to be under-estimated. There are a number of potentially important diseases that were excluded from the analyses because of the lack of data to allow an estimate of the proportion of treatment costs that could be attributed to obesity, for example, depression, hyper-lipidemia and back pain, because no studies were identified in the review that reported the relative risk for obese individuals of developing these conditions. Other limitations of the study are the differing definition of obesity in some of the studies (although no bias was determined), the application of the international studies to the UK population and the cost to other public organisations is not covered e.g. costs to social services. Tackling Obesity in England. Available at: www.nao.org.uk/publications/0001/tackling_obesity_in_england.aspx
Taking Part Survey

The Taking Part Survey (TPS) was commissioned by the Department for Culture, Media and Sport (DCMS) working in partnership with several of its non-departmental public bodies. The survey collects data about engagement and non-engagement in culture, leisure and sport. This information helps the DCMS and its partner bodies to better understand those who do, and do not, engage with its sectors. The DCMS current Public Service Agreements (PSAs) have a significant focus on increasing participation in Arts, Sport, Museums and Heritage, particularly by a range of priority groups. The TPS has now become the mechanism for monitoring progress against several of these targets. Since mid-July 2005, BMRB Social Research (now integrated with TNS Social Research) has been conducting continuous face to face interviews with adults aged 16 or over living in private households in England From January 2006, children aged 11-15 were included within the survey and in 2008/09, children aged 5-15 were surveyed. Data from the Taking Part Survey are used in Chapters 4 and 5 (Physical activity among adults and children).
The Taking Part 2010/11 Adult and Child Report, Statistical Release. Available at: Main Report: http://www.culture.gov.uk/images/research/taking-part-Y6-child-adult-report.pdf Headline figures from the 2009/10 Taking Part Adult and Child Report: http://www.culture.gov.uk/publications/7386.aspx This is a National Statistic.
Other related information:

Taking Part: The National Survey of Culture, Leisure and Sport Final assessment of progress on PSA3: complete estimates from year three, 2007/08. Available at: http://www.culture.gov.uk/reference_library/publications/5653.aspx 2007 Comprehensive Spending Review (PSA21 : indicator 6). http://www.hm-treasury.gov.uk/pbr_csr07_psacommunities.htm
Appendix B: Technical notes

Overweight and obesity
Adults BMI Children - UK National BMI percentile classification Children - International Obesity Task Force (IOTF) NICE guidance

Activity types, frequency, duration, and intensity Objective measures of physical activity - Accelerometry Objective measures of physical activity - Summary activity levels Objective measures of physical activity - Fitness English, Scottish and Welsh comparisons among adults

Summary activity levels
Active sport Diet and nutrition

Fruit and vegetable portions Estimated Average Requirements and Reference Nutrient Intakes
Health Survey for England

Age standardisation Use of HSE data from different years General Health Questionnaire GHQ12 Blood pressure Weighted HSE data used in Chapter 7: Health Outcomes Equivalised household income quintiles Logistic regression
Hospital Episode Statistics: coding for bariatric surgery
Overweight and obesity

Adults BMI
Overweight and obesity among adults is measured in the Health Survey for England (HSE) using Body Mass Index (BMI). The BMI is calculated by dividing weight in kilograms, by the square of the height in metres (kg/m2).
BMI =
Weight (kg ) Height 2 (m 2 )
Adults are classified into the following BMI groups:
BMI range (kg/m2) Under 18.5 18.5 to less than 25 25 to less than 30 30 and over 40 and over 25 and over
Definition Underweight Normal Overweight Obese Morbidly obese Overweight including obese
Children British 1990 growth reference percentiles

Due to differences in growth rates among boys and girls at each age, it is not possible to apply a universal formula in calculating obesity and overweight prevalence in children. Each sex and age group therefore needs its own level of classification for obesity. The British 1990 growth reference (UK90) percentiles is therefore used which gives a BMI threshold for each age above which a child is considered overweight or obese; those children whose BMI is above the 85th percentile are classified as overweight and those children whose BMI is above the 95th percentile are classified as obese. The percentiles are given for each sex and age. According to this method, 15% and 5% of children in 1990 had a BMI above this level and were thus classified as overweight/obese. Increases over 15% and 5% in the proportion of children who exceed the reference 85th/95th percentiles over time indicate an upward trend in the prevalence of overweight and obesity. Unless otherwise specified figures relating to the prevalence of childhood obesity in this report are determined by this method.
International Obesity Task Force (IOTF)

This is an alternative method of determining childhood obesity. It is based on BMI reference data from six different countries around the world (over 190,000 subjects in total aged 0 to 25 from UK, Brazil, Hong Kong, the Netherlands, Singapore, and the United States). The BMI percentile curves that pass through the values of 25kg/m2 and 30 kg/m2 (standard cut-off points for overweight and obesity, respectively) at age 18 were smoothed for each national dataset and then averaged. The averaged curves were then used to provide age and sex-specific BMI cut-off points for children and adolescents aged 2 to 18. The benefit of this approach is that it allows international comparisons of levels of obesity in children to be made. Figures derived using this method are discussed in Chapter 3 (Obesity among children) of this bulletin commenting upon results from Foresight: Tackling Obesities: Future Choices. For further information this report is available at: http://www.foresight.gov.uk/OurWork/ActiveProjects/Obesity/KeyInfo/Index.asp
National Institute for Health and Clinical Excellence (NICE) guidance

NICE guidance suggests that the measurement of waist circumference should be used for people with a BMI less than 35kg/m2 to assess health risks (as shown in the table below). For adults with a BMI of 35kg/m2 or more, risks are assumed to be very high with any waist circumference.
Assessing risk from overweight and obesity

Waist circumference Low High Very high Normal weight No increased risk No increased risk Increased risk Overweight (25 to less than 30 kg/m2) No increased risk Increased risk High risk Obesity I (30 to less than 35 kg/m2) Increased risk High risk Very high risk For men, low waist circumference is defined as less than 94 cm, high as 94102 cm, and very high as greater than 102 cm. For women, low waist circumference is less than 80 cm, high is 8088 cm and very high as greater than 88 cm. BMI classification
Source: National Institute for Health and Clinical Excellence (NICE) guidelines
Further information on the NICE guidelines is available at: http://www.nice.org.uk/guidance/CG43
Physical activity and fitness among adults

The Health Survey for England (HSE) 2008 presented information on physical activity and fitness. Information on Adults self-reported physical activity in the last four weeks was collected using an enhanced version of the HSE physical activity questionnaire, developed and tested in 2007. The physical activity module was first used in the HSE in 1991,repeated in 1992 to 1994 with minor changes, and received more substantial revisions in 1997 and 1998 (producing what is generally referred to as the long version of the questionnaire). A shorter version of the questionnaire was introduced in 1999, when the focus was minority ethnic groups; the shorter questionnaire was repeated in 2002, 2003 and 2004. In 2006, a slightly modified version of the long (1998) form of the questionnaire was used. In 2008, a new occupational physical activity set of questions were included within the questionnaire and additional questions on sedentary behaviour were also asked. To enable continuation of these trend data, the same methods for analysis were used in 2008, as well as the more detailed definition possible for 2008 using the enhanced questionnaire.
Activity types, frequency, duration, and intensity

Details about four main types of physical activity were included in the questionnaire. For most activities in which they had participated, respondents were asked on how many days in the last four weeks they had done the activity for at least 10 minutes, and the average length of time spent on those days. 1. Home activity consisted of housework and gardening/DIY/building that lasted 10 minutes or more. The lead-in question was Have you done any housework in the last four weeks? Participants were shown a card with a list of examples of light housework and were asked if they had done any of the listed activities. They were then asked about heavy housework by showing another card with higher intensity activities, for which frequency was assessed. A similar sequence of questions was asked for gardening/DIY/building work. Frequency of light home activity (i.e. those activities listed in the first set of show cards) was not assessed. 2. Walks of 10 minutes or more. The key question was During the past four weeks, on how many days did you do a walk of least 10 minutes? Walking intensity was assessed by asking participants to rate their usual walking pace (slow / average / fairly brisk / fast). 3. Sports and exercise activities that lasted 10 minutes or more. For sports and exercise activities in the four weeks prior to interview, participants were asked Can you tell me on how many separate
days did you do (name of specific sport and exercise activity) for at least 10 minutes at a time during the past four weeks?, followed by a question about the activitys usual duration on these days. The intensity of these activities was assessed by asking participants whether or not the activity had made them out of breath or sweaty. 4. Occupational activities that lasted 10 minutes or more. After establishing whether participants did any paid or unpaid work in the last four weeks, the key question was Which of these did you do whilst working? Sitting down or standing up; walking at work; climbing stairs or ladders; lifting, carrying or moving heavy loads, followed by a question about the time spent on that type of activity on these days. As in previous years, participants were also asked Thinking about your job in general would you say that you arevery physically active; fairly physically active; not very physically active; not at all physically active?
Objective measures of physical activity Accelerometry

Accelerometers provide objective information on the frequency, intensity, and duration of both physical activity and sedentary behaviour. Using an accelerometer to collect activity data has the advantages of being objective and providing standardised measures, unlike self-report of activity. Direct monitoring reduces recall bias and other problems of subjectivity. Within the HSE 2008, a sub-sample of adults were asked to wear an accelerometer for the week following the completion of the questionnaire. Participants wore the monitor during waking hours and kept a record of activities when the monitor was not worn, for example while swimming.
Summary activity levels

The summary measure of physical activity levels groups informants in a way that allows comparisons to the Chief Medical Officer (CMO) physical activity guidelines, which for adults are that they should achieve a total of at least 30 minutes of at least moderate activity, either in one session or in multiple bouts of at least 10 minutes duration, on five or more days of the week. The CMO also recommends that at least twice a week this should include activities to improve bone health, muscle strength and flexibility. Moderate intensity activities have an energy cost of at least 5 kcal/min but less than 7.5 kcal/min and include heavy housework or gardening and sports which make the individual breathe heavily and become sweaty. The summary activity level classification for both the self-reported and objective measures of physical activity are as follows: Meets recommendations: 20 or more occasions of moderate or vigorous activity of at least 30 minutes duration in the last four weeks (i.e. at least five occasions per week on average). This category corresponds to the minimum activity level required to gain general health benefits (e.g. reduction in the relative risk for cardiovascular morbidity). However, it does not necessarily indicate the extent of activity required for optimal cardiovascular fitness or for optimal weight control.
Some activity: Four to 19 occasions of moderate or vigorous activity of at least 30 minutes duration in the last four weeks (i.e. at least one but fewer than five occasions per week on average). Low activity: Fewer than four occasions of moderate or vigorous activity of at least 30 minutes duration in the last four weeks (i.e. less than once per week on average).
For comparisons of summary activity levels over time, HSE 2008 self-report data have been analysed with the lower duration for activities set to 30 minutes, to be comparable with results obtained from the shorter questionnaire used in 2003 and 2004. 1997 and 1998 data were also reanalysed using this longer minimum duration, to enable data for the five years to be compared. In 2008 bouts of activity lasting at least 10 minutes counted towards meeting the recommendations. Therefore, three bouts of activity lasting at least 10 minutes each would be considered sufficient to meet the recommendations on that day. Because bouts of activity lasting a minimum of 30 minutes are being used for comparison with results from previous years, the results presented in this chapter are likely to be an underestimate of the proportion of the population that meets the revised recommendations.
Fitness
Physical fitness, also called functional capacity, is the ability of an individual to perform work. The most common form of work capacity assessed is the aerobic component, measured by the maximal oxygen uptake (VO2max). Oxygen uptake refers to the use of oxygen by the bodys cells. Oxygen uptake rises rapidly on starting exercise and reaches a plateau (steady state VO2) by three to five minutes of steady exercise. Maximal oxygen uptake is reached when oxygen uptake does not increase despite further increase in intensity of the exercise (e.g. running faster or up a steeper incline), although not everyone has such a plateau. VO2max is typically achieved by exercise that involves only about half the total body musculature. In the HSE 2008, a sub-sample of adults aged 16 to 74 had their fitness levels assessed using a step test. An indirect method of measuring physical fitness was chosen because of the survey design of conducting the tests in participants homes; direct measurement of oxygen consumption was therefore not possible. The decision to use a step test rather than a treadmill or cycle ergometer was also made for practical reasons. A single step was chosen as this was easier for the nurses to transport to participants homes than the double step that was piloted with considerable problems in 2005. The physical fitness test consisted of the step test originally developed by researchers at Medical Research Council (MRC) Cambridge. The test involved the subject stepping up and down a single step. The pace was given digitally by the nurses laptop and the stepping lasted a maximum of eight minutes. The pace of stepping increased through the duration of the test. The participant stepped up and down first at a slow pace for one minute, at a rate of one leg movement per second. This equates to one body lift (i.e. the respondent stepping up and back down from the step) over four seconds. Then the stepping pace gradually increased over the next seven minutes until, by the end of the eighth minute, the frequency was 33 body lifts per minute (i.e. one body lift in just under two seconds). The participants heart rate was the primary outcome measure of the step test. The heart rate was recorded at 30 second intervals during the test and at 15 second intervals for two minutes after the step test ended. The participant wore a Polar heart rate monitor round the chest which transmitted the heart rate to a receiver worn on the participants wrist. Using a stop watch to mark the time
intervals, the nurse recorded the heart rate detected by the monitor. These heart rate measurements were then combined with the resting heart rate obtained earlier during blood pressure measurement to determine the submaximal relationship between heart rate and oxygen uptake. This relationship was then extrapolated up to age-predicted maximal heart rate to provide an estimate of the individuals maximal oxygen uptake (VO2max), the overall level of fitness. Fitness categories in the HSE 2008 were defined as follows: Light exertion: requiring less than 30% of that persons VO2max Moderate exertion: requiring 30-64% of that persons VO2max Severe exertion: requiring 65-100% of that persons VO2max (therefore unsustainable for any substantial length of time) Maximal exertion: requiring more than 100% of that persons VO2max
English, Scottish and Welsh comparisons among adults

The Scottish Health Survey (SHS) 2008 physical activity module is based on the Allied Dunbar National Fitness Survey (ADNFS). A very similar questionnaire was used in both the 1998 and 2003 SHS and therefore comparisons over time are uncomplicated. Participants were asked about there participation in 4 types of activities: Home-based activities (housework, gardening, building work and DIY); Walking; Sports and exercise; Activity at work.
Prior to the SHS 2008, duration of participation in physical activities was set to 15 minutes. However, as the CMO recommendations state that activity can be accumulated in bouts of 10 minutes the questionnaire was updated in 2008 to include activities of 10 to 14 minutes duration. The SHS 2008 also collected information on the amount of time that participants spent in sedentary behaviours. The Welsh Health Survey asked adults on which days in the past week they did at least 30 minutes of light, moderate, and vigorous exercise or physical activity. In this survey blocks of activity lasting more than 10 minutes, which were done on the same day, count towards the full 30 minutes. Respondents were asked to include physical activity which is part of their job. Examples of each type of activity are: light activity - housework or golf moderate activity - heavy gardening or fast walking vigorous activity - running or aerobics.
The Chief Medical Officer (CMO) of England recommends that children and young people should do a minimum of 60 minutes of at least moderate intensity physical activity each day. Children should also participate in activities that improve bone health, muscle strength and flexibility at least twice a week. In HSE 2008, the childrens physical activity questionnaire was completely revised. The key changes to the 2008 questionnaire were: A new division of sports and activities into formal and informal; and as well as the activities on the show cards, participants were asked about any other similar activities they had done, and these were recorded individually; For each activity undertaken, participants were asked on which specific days of the week they had done them, rather than on how many weekdays and weekend days; For each day that the participant had done an activity, they were asked how long they had done it (in hours and minutes), rather than giving an average for all the days using half hour bands.
Due to the significant revisions to the 2008 childrens physical activity questionnaire, the results reported here are not directly comparable with previous HSE reports that present findings on child physical activity. The HSE 2008 self-report questionnaire collected details about the out-of-school activity of children aged 2 to 15. The decision to exclude activities which are part of the school curriculum was taken for three reasons. Firstly, it was assumed that, generally speaking, the amount of activity carried out by children as part of school lessons would be similar for all children (according to their age) and would contribute to a standard additional amount of activity for each child. Secondly, activities as part of the school curriculum would generally be compulsory and the survey was more concerned with what children would do of their own choice. Thirdly, since a large proportion of data would be collected by proxy from a parent, it was felt that information about activities during school lessons would be less accurate than information about leisure time activities. However, any activities carried out on school premises but not as part of school lessons (e.g. after school clubs, during break times) were covered by the questions asked. For pre-school children, activities done at any nursery or playgroup that the child attended were included. The groups of activities for children: 1. Walking (not including to or from school): Walking was presented as part of the informal group of activities. It has been analysed separately as an activity of policy interest. The walks included are of any duration. 2. Informal activities: Activities in this group include cycling, dancing, skating, trampolining, hopscotch, active play, skipping rope, and housework and gardening. 3. Formal sports: Activities in this group include any organised team sports such as football, rugby, cricket, and netball, as well as running or athletics, all types of swimming, gymnastics, weight training, aerobics and tennis. Where the total physical activity variable has been included in the tables, it is an aggregate of the grouped activities listed above.
4. Walking or cycling to and from school is reported separately from other walking and cycling in these analyses, because active travel to and from school is an important opportunity for physical activity amongst children. The structure of the questions about active travel to school differed from the structure for all other types of physical activity, since journeys were not related to specific weekdays. Thus it is not possible to combine walking and cycling to school with other occasions of walking and cycling in assessing the total amount of activity for the summary activity levels.
Objective measures of physical activity

A sub-sample of children aged 4 to 15 were asked to wear an accelerometer during the week following the interview. The accelerometer provides a measure of frequency, intensity and duration of physical activity, allowing classification of activity levels as sedentary, light, moderate and vigorous. The accelerometer was worn on a specially provided belt and each child was asked to wear the accelerometer during waking hours for seven consecutive full days; parent co-operation was also required, particularly for younger children. The device was taken off for activities such as showering or swimming, as the Actigraph is not waterproof. Also, some children removed their monitor during contact sports such as karate or rugby. For adults, current evidence suggests that moderate or vigorous activity should be accumulated in bouts of at least 10 minutes to count towards meeting government at the time recommendations, as it is these bouts of sustained activity that provide health benefits. However, this is not a realistic requirement for children, since the nature of childrens physical activity typically differs from adults, being less likely to involve clearly defined periods of specific activities. Thus childrens activity is much more likely to be sporadic, occurring in short bursts. For this reason, in keeping with other studies, all of childrens moderate or vigorous activity has been taken into account in assessing whether they have met the then government guidelines for physical activity, rather than imposing a requirement for bouts of 10 minutes or more. Summary activity levels for both self-reported and objective measures of physical activity in children are: Meets recommendations: At least 60 minutes of moderate activity on all seven days in the last week. Some activity: 30-59 minutes of moderate activity on all seven days in the last week. Low activity: Fewer than 30 minutes of moderate activity on each day, or moderate activity of 60 minutes or more on fewer than seven days in the last week.
Active sport
The Department for Culture, Media and Sport Public Service Agreement (PSA) and the Taking Part Survey define the following as active sports: swimming or diving; BMX, cyclo-cross, mountain biking; cycling; bowls; tenpin bowling; health, fitness, gym or conditioning activities; keep fit, aerobics, dance exercise; judo; karate; taekwondo; other martial arts; weight training; weightlifting; gymnastics; snooker, pool, billiards; darts; rugby league and union; American football; football; cricket; hockey; baseball/softball; netball; tennis; badminton; squash; basketball; table tennis; track and field athletics; jogging, cross-country, road running; angling or fishing; canoeing; windsurfing or boardsailing; ice skating; golf, pitch and putt, putting; skiing; horse riding; climbing/mountaineering; hill trekking or
backpacking; karting; volleyball; orienteering; rounders; rowing; boxing; waterskiing; lacrosse; yoga; fencing; and other types of sport for example roller-blading, street hockey, skateboarding, water polo, surfing, scuba diving, gliding, hang/paragliding, parachuting or parascending are also included in the valid activities which are recorded in the other sports category. Utility cycling and all forms of walking are excluded from the active sport target.
Diet and nutrition

Fruit and vegetable portions
Fruit and vegetable consumption is measured in portions; using guidelines specified in the 5 a day programme. The government recommends that people should eat five portions of fruit and vegetables a day. Five portions are defined as 400g of fruit and vegetables per day, an average of 80g per portion. A variety of foodstuffs represent a portion, including vegetables (fresh, frozen, canned), vegetables in composite dishes (such as pies or curries), salads, pulses, fruit (fresh, frozen, canned, dried), fruit in composites (such as pies or crumbles) and fruit juice. Below is a table showing the recommended portions sizes of the different types of fruit and vegetables in terms of everyday household measures. These measures have been used by the Health Survey for England when collecting data through dietary recall and for estimation of the number of portions respondents have consumed. The Low Income Diet and Nutrition Survey also followed the government guidelines in terms of what and how much counts as a portion, but estimated the weight of the fruit and vegetables consumed and divided by 80 (or 157 in the case of fruit juice to convert to millilitres) to determine the number of portions. According the current guidelines, fruit juice, regardless of how much is drunk in excess of one small glass (150ml), only counts as a maximum of one portion per day. This is due to its low fibre content and its high content of non-milk extrinsic sugars, which, when consumed in too high a quantity can lead to tooth decay and dental health problems. Pulses (such as beans, lentils and chick peas) can also only contribute a maximum of one portion per day regardless of how much is consumed; whilst they do contain fibre, they do not provide the same mixture of vitamins, minerals and other nutrients that can be obtained from fruit and vegetables. Due to their high starch content, potatoes in any form (including sweet potato varieties) and other starchy vegetables, such as plantain and green bananas, do not count towards the 5 a day portions. Nuts and seeds do not count towards the 5 a day portions. These guidelines and quantities are based on adult requirements and while the government recommends that children over the age of five should also consume five portions of a variety of the foodstuffs shown below, their portion sizes may be smaller. However, survey measures of fruit and vegetable consumption among children are based on adult portion sizes.
Food item Vegetables (fresh, raw, tinned and frozen) Pulses Salad Vegetables in composites, such as vegetable chilli Very large fruit, such as melon Large fruit, such as grapefruit Medium fruit, such as apples Small fruit, such as plums Very small fruit, such as blueberries Dried fruit Frozen fruit / tinned fruit Fruit in composites, such as stewed fruit Fruit juice
Portion size 3 tablespoons 3 tablespoons 1 cereal bowl 3 tablespoons 1 average slice Half a fruit 1 fruit 2 fruits 2 average handfulls 1 tablespoon 3 tablespoons 3 tablespoons 1 small glass (150ml)
Estimated Average Requirements and Reference Nutrient Intakes

In 1991 the Committee on Medical Aspects of Food and Nutrition Policy (COMA) recommended that population average intakes of different macronutrients should not exceed specified limits. For example the population average intakes of total fat, saturated fatty acids and non-milk extrinsic sugars (principally added sugars) should not exceed 35 per cent, 11 per cent and 11 per cent of food energy respectively. Energy intake is compared against the Estimated Average Requirement (EAR) for a group. Estimates of energy requirements for different populations are termed EARs and are defined as the energy intake estimated to meet the average requirements of the group. About half the people in the group will usually need more energy than the EAR and half the people in the group will usually need less. Nutrient intakes derived from surveys are compared with Reference Nutrient Intakes (RNIs). These RNIs represent the best estimate of the amount of a nutrient that is enough, or more than enough, for about 97 per cent of people in a group. If average intake of a group is at the level of the RNI, then the risk of deficiency in the group is very small.
Health Survey for England (HSE)

Age Standardisation
Adult data have been age-standardised throughout the HSE 2009 to allow comparisons between groups after adjusting for the effects of any differences in their age distributions. When different subgroups are compared in respect of a variable on which age has an important influence, any differences in age distributions between these sub-groups are likely to affect the observed differences in the proportions of interest. All age standardisation has been undertaken separately within each gender, expressing male data to the overall male population and female data to the overall female population. When comparing data for the two genders, it should be remembered that no age standardisation has been introduced to remove the effects of the genders different age distributions.
Footnotes have been provided in this report on tables where age standardised figures have been presented and include the following variables: equivalised household income quintile and Government Office Region. Further information on overweight and obesity prevalence across Strategic Health Authorities (SHAs) is given in HSE: Health and Lifestyle Indicators for Strategic Health Authorities 1994 - 2002. This includes an age-standardised time series of overweight and obesity prevalence levels by SHA. This publication is available at: http://www.dh.gov.uk/PublicationsAndStatistics/PublishedSurvey/HealthSurveyForEngland/HealthSur veyResults/HealthSurveyResultsArticle/fs/en?CONTENT_ID=4077728&chk=5Mjlqy
Use of HSE data from different years

This report contains data and information from different years of the HSE. This is to provide the most recent information for the general population that was available at the time of publishing. Where possible, data has been used from the most recent HSE 2009 results, however there are some restrictions to this. In some cases data is not presented in the HSE reports in the format required for this report, therefore additional analysis of the data set is undertaken. At the time of publishing, the HSE 2009 data set was not available for such additional analysis; therefore data from previous HSE survey years was used as appropriate.
Chapter 7 discusses blood pressure, longstanding illnesses and GHQ12 (12-item General Health Questionnaire see below) by BMI and waist circumference. Analysis of these health conditions by BMI and waist circumference was carried out on the 2008 dataset specifically for this publication.
GHQ12
GHQ12 is the 12-item General Health Questionnaire designed to measure self-assessed general health, acute sickness leading to reduction in recent activity and psychosocial wellbeing.
Blood pressure
The levels of blood pressure used to define hypertension in the HSE are in accordance with the latest guidelines on hypertension management. To compute the prevalence of hypertension, adult informants were classified in one of four groups on the basis of their SBP (systolic blood pressure) and DBP (diastolic blood pressure) readings and their current use of anti-hypertensive medication. Normotensive-untreated SBP<140 mmHg and DBP<90 mmHg, not currently taking any prescribed drugs that lower blood pressure Hypertensive-controlled SBP<140 mmHg and DBP<90 mmHg, currently taking medication prescribed to lower blood pressure
Hypertensive-uncontrolled SBP140 mmHg and DBP90 mmHg, currently taking medication prescribed to lower blood pressure Hypertensive-untreated SBP140 mmHg and DBP90 mmHg, not currently taking any prescribed drugs that lower blood pressure
The last three categories together are considered as hypertensive for the purpose of this report. The definition of hypertension used for clinical purpose talks about sustained levels of high blood pressure, while HSE only measures blood pressure at one point in time. This needs to be taken into account when interpreting the results. Hypertensive controlled and hypertensive uncontrolled groups are all those who take drugs that were prescribed to lower their blood pressure.
Weighted HSE data used in Chapter 7: Health Outcomes

Tables 7.1 and 7.2 show prevalence of blood pressure levels by BMI and waist circumference, tables 7.3 and 7.4 show longstanding illness by BMI and waist circumference and table 7.5 shows GHQ12 score by BMI. Questions on longstanding illness are asked during the interview visit, whereas blood pressure and waist circumference are measured during the nurse visit. Different weights are used within the HSE depending on which stage of the process the information is collected (interview or nurse). Totals in tables include those without a valid BMI recorded. Therefore the weighting used in analysis needs to take account the stage of the process for which the associated variable is collected. The blood pressure variable is collected by the nurse and therefore uses the nurse weight to calculate weighted prevalence totals, but weighted totals for longstanding illness are based on the interview weight since these are collected at the interview stage, however the prevalence and weighted bases for each BMI status (normal, overweight or obese) for these conditions are based on the nurse weight. Further details of weighting can be found in the methodology chapter of the Health Survey for England 2007: Healthy Lifestyles: Knowledge, attitudes and behaviour www.ic.nhs.uk/pubs/hse07healthylifestyles
Equivalised household income quintiles

Household income was established in the HSE by means of a show-card on which banded incomes were presented. There has been increasing interest recently in using measures of equivalised income that adjust income to take account of the number of persons in the household. To derive this, each household member is given a score depending, for adults, on the number of adults apart from the household reference person, and for dependent children, on their age. The total household income is divided by the sum of the scores to provide the measure of equivalised household income. All individuals in each household were allocated to the equivalised household income quintile to which their household had been allocated.
Logistic Regression
Logistic regression is a statistical technique that examines the relationship between an outcome variable and a number of predictor variables. In the table presented, the outcome variable is being in the high health risk category.
Results are displayed as odds ratios for the final model. Odds are expressed relative to a reference category. An odds ratio of above 1 implies that people within the category are more likely to be in the high health risk category. The 95% confidence interval is also shown. Where the interval does not include 1, the association is unlikely to be due to random chance and we say the category is significantly different from the reference category. For example, the odds ratio for women in the category Used to smoke cigarettes regularly is 1.36, with a 95% confidence interval of 1.08-1.72. The reference category for this variable is Never smoked. As the odds ratio is greater than 1 and the 95% confidence interval does not contain 1, we say that women who used to smoke cigarettes are more likely to be in the high risk health category than women who have never smoked.
Hospital Episode Statistics codes: coding for Bariatric Surgery used in Tables 7.12 and 7.13
The term bariatric surgery is often used to define a group of procedures that can be performed to facilitate weight loss although these procedures can be performed for conditions other than weight loss. It includes stomach stapling, gastric bypasses and sleeve gastrectomy. Using Hospital Episode Statistics (HES) data held at The NHS Information Centre, the number of Finished Consultant Episodes (FCEs) for bariatric surgery has been determined where the primary diagnosis was obesity (ICD-10 code E66) and the main or secondary procedure was one of the following OPCS codes for the relevant time periods. OPCS-4.2 codes were used between 1996/97 to 2005/06, OPCS-4.3 codes for 2006/07, OPCS-4.4 codes for 2007/08 and 2008/09, OPCS-4.5 codes for 2009/10 and OPCS-4.6 codes for 2010/11. The following OPCS 4.2 codes have been used for bariatric surgery from 1996/97 to 2005/06 inclusive: G27.2 Total gastrectomy and anastomosis of oesophagus to duodenum G27.3 Total gastrectomy and interposition of jejunum G27.4 Total gastrectomy and anastomosis of oesophagus to transposed jejunum G27.5 Total gastrectomy and anastomosis of oesophagus to jejunum nec G27.8 Other specified total excision of stomach G27.9 Unspecified total excision of stomach G28.1 Partial gastrectomy and anastomosis of stomach to duodenum G28.2 Partial gastrectomy and anastomosis of stomach to transposed jejunum G28.3 Partial gastrectomy and anastomosis of stomach jejunum nec G28.8 Other specific partial excision of stomach G28.9 Unspecified partial excision of stomach G30.1 Gastroplasty nec G30.2 Partitioning of stomach nec G30.8 Other specified plastic operations on stomach G30.9 Unspecified plastic operations on stomach G31.1 Bypass of stomach by anastomosis of oesophagus to duodenum G31.2 Bypass of stomach by anastomosis of stomach to duodenum G31.3 Revision of anastomosis of stomach to duodenum G31.4 Conversion to anastomosis of stomach to duodenum G31.8 Other specified connection of stomach to duodenum G31.9 Unspecified connection of stomach to duodenum G31.0 Conversion from pervious anastomosis of stomach to duodenum G32.0 Conversion from previous anastomosis of stomach to transposed jejunum G32.1 Bypass of stomach by anastomosis of stomach transposed to jejunum G32.2 Revision of anastomosis of stomach to transposed jejunum G32.3 Conversion to anastomosis of stomach to transposed jejunum G32.8 Other specified connection of stomach to transposed jejunum G32.9 Unspecified connection of stomach to transposed jejunum
G33.1 Bypass of stomach by anastomosis of stomach to jejunum nec G33.2 Revision of anastomosis of stomach to jejunum G33.3 Conversion of anastomosis of stomach to jejunum nec G33.8 Other specified other connection of stomach to jejunum G33.9 Unspecified other connection of stomach to jejunum G33.0 Conversion from previous anastomosis of stomach to jejunum nec G38.8 Other specified other open operations on stomach G48.1 Insertion of gastric bubble G48.2 Attention of gastric bubble The following OPCS 4.3/OPCS 4.4 codes in addition to the above have been used for bariatric surgery from 2006/07 to 2008/09 inclusive: G28.4 Sleeve gastrectomy and duodenal switch G28.5 Sleeve gastrectomy nec G30.3 Partitioning of stomach using band G30.4 Partitioning of stomach using staples G31.5 Closure of connection of stomach and duodenum G31.6 Attention of connection of stomach and duodenum G32.4 Closure of connection of stomach to transposed jejunum G32.5 Attention to connection of stomach to transposed jejunum G33.5 Closure of connection of stomach to jejunum nec G33.6 Attention to connection of stomach to jejunum G38.7 Removal of gastric band G71.6 Duodenal switch The following OPCS-4.5 procedure codes have been used for bariatric surgery for 2009/10: G27.1 Total gastrectomy and excision of surrounding tissue G27.2 Total gastrectomy and anastomosis of oesophagus to duodenum G27.3 Total gastrectomy and interposition of jejunum G27.4 Total gastrectomy and anastomosis of oesophagus to transposed jejunum G27.5 Total gastrectomy and anastomosis of oesophagus to jejunum nec G27.8 Other specified total excision of stomach G27.9 Unspecified total excision of stomach G28.1 Partial gastrectomy and anastomosis of stomach to duodenum G28.2 Partial gastrectomy and anastomosis of stomach to transposed jejunum G28.3 Partial gastrectomy and anastomosis of stomach to jejunum nec G28.8 Other specified partial excision of stomach G28.9 Unspecified partial excision of stomach G31.1 Bypass of stomach by anastomosis of oesophagus to duodenum G31.2 Bypass of stomach by anastomosis of stomach to duodenum G31.3 Revision of anastomosis of stomach to duodenum
G31.4 Conversion to anastomosis of stomach to duodenum G31.8 Other specified connection of stomach to duodenum G31.9 Unspecified connection of stomach to duodenum G31.0 Conversion from previous anastomosis of stomach to duodenum G32.0 Conversion from previous anastomosis of stomach to transposed jejunum G32.1 Bypass of stomach by anastomosis of stomach to transposed jejunum G32.2 Revision of anastomosis of stomach to transposed jejunum G32.3 Conversion to anastomosis of stomach to transposed jejunum G32.8 Other specified connection of stomach to transposed jejunum G32.9 Unspecified connection of stomach to transposed jejunum G33.1 Bypass of stomach by anastomosis of stomach to jejunum nec G33.2 Revision of anastomosis of stomach to jejunum G33.3 Conversion of anastomosis of stomach to jejunum nec G33.8 Other specified other connection of stomach to jejunum G33.9 Unspecified other connection of stomach to jejunum G33.0 Conversion from previous anastomosis of stomach to jejunum nec G48.1 Insertion of gastric bubble G48.2 Attention to gastric bubble G28.4 Sleeve gastrectomy and duodenal switch G28.5 Sleeve gastrectomy NEC G30.3 Partitioning of stomach using band G30.4 Partitioning of stomach using staples G30.5 Maintenance of gastric band G31.5 Closure of connection of stomach to duodenum G31.6 Attention to connection of stomach to duodenum G32.4 Closure of connection of stomach to transposed jejunum G32.5 Attention to connection of stomach to transposed jejunum G33.5 Closure of connection of stomach to jejunum NEC G33.6 Attention to connection of stomach to jejunum G38.7 Removal of gastric band G71.6 Duodenal switch The following OPCS-4.6 procedure codes, in addition to the above codes used in 2009/10, have been used for bariatric surgery for 2010/11: G48.5 Insertion of gastric balloon G48.6 Attention to gastric balloon G71.7 Reversal of duodenal switch
Appendix C: Government policy, targets and outcome indicators

Public Health Outcomes Framework
Recently launched in January 2012, the Public Health Outcomes Framework is comprised of a number of indicators against which Public Health delivery partners will be encouraged to demonstrate improvement. The introduction of the framework will act as a stimulus to encourage public health delivery partners to make significant improvements in services and share best practice more widely. The intention is that the introduction of benchmarking (through the indicator measures) will have a strong impact on improving public health outcomes this is consistent with recent evidence that the introduction of indicator measures can have a strong influence on achieving successful Health Outcomes - and will have a direct effect on protecting and improving the nations health. For further information, see link: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_13235 8
Healthy Lives, Healthy People: A call to action on obesity in England

This document published in October 2011 sets out how the new approach to public health will enable effective action on obesity and encourages a wide range of partners to play their part. For a full copy of the report, follow the link below: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_13040 1
The eatwell plate

Updated from the Balance of Good Health in August 2011, the eatwell plate is a policy tool that defines the Governments recommendations on healthy diets. It makes healthy eating easier to understand by giving a visual representation of the types and proportions of foods needed for a healthy and well balanced diet. For further information, see link: www.dh.gov.uk/en/Publichealth/Nutrition/DH_126493
Start active, stay active: a report on physical activity from the four home countries' Chief Medical Officers
Launched in July 2011, this UK-wide report presents guidelines on the volume, duration, frequency and type of physical activity required across the lifecourse to achieve general health benefits. It is aimed at the NHS, local authorities and a range of other organisations designing services to promote physical activity. The document is intended for professionals, practitioners and policymakers concerned with formulating and implementing policies and programmes that utilise the promotion of physical activity, sport, exercise and active travel to achieve health gains. For further information, see link:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_1 28209
Public Health Responsibility Deal

What we eat, how much we drink and how active we are is heavily shaped by our environment. Creating the right environment can encourage and empower people to take responsibility for their health and make healthy choices. Launched on 15 March 2011, the Public Health Responsibility Deal has been established to tap into the potential for businesses and other organisations to improve public health and tackle health inequalities through their influence over food, alcohol, physical activity and health in the workplace. For further information, see link: www.dh.gov.uk/en/Publichealth/Publichealthresponsibilitydeal/index.htm
Plans for the Legacy from the 2012 Olympic and Paralympic Games
The Coalition Government published its plans in December 2010 to producing a safe and secure Games that leaves a lasting legacy. The task is not only to ensure that the Games are a success as iconic sporting occasions but also that the most is made from the Games for the nation. The Government will focus on four areas in doing this: Harnessing the United Kingdoms passion for sport to increase grass roots participation, particularly by young people and to encourage the whole population to be more physically active Exploiting to the full the opportunities for economic growth offered by hosting the Games Promoting community engagement and achieving participation across all groups in society through the Games; and Ensuring that the OIympic Park can be developed after the Games as one of the principal drivers of regeneration in East London.
For further information, see link: http://www.culture.gov.uk/publications/7674.aspx
Healthy Lives, Healthy People: Our Strategy for Public Health in England
This latest White Paper, published in November 2010, sets out the Governments long-term vision for the future of public health in England. The aim is to strengthen both national and local leadership. For a full copy of the report follow the link: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_12194 1
Public Service Agreements

The new coalition government ended the system of Public Service Agreements (PSAs) set at national level in 2010. For the meantime these are to be replaced by Departmental business plans,
which each Government department has recently published setting out the details of its reform plans, including its: vision and priorities to 2014-15; structural reform plan, including actions and deadlines for implementing reforms over the next two years; and contribution to transparency, including the key indicators against which it will publish data to show the cost and impact of public services and departmental activities. However some PSA targets have been included in this report as they may have been in place when the data were collected.
A link to the Department of Healths Business Plan (2011-2015) can be found following this link: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_12139 3
National Indicator Set

The Audit Commission was commissioned by the previous government to publish the National Indicator Set (NIS) as part of the assessment of local areas' Comprehensive Area Assessment (CAA). In May 2010, the new government announced their intention to abolish CAA. The Audit Commission stopped work on updates to the assessments and decided not to update the National Indicator data on the CAA website.
Change4Life
In January 2009, the previous government launched an ambitious new campaign Change 4 Life a society wide movement that aims to prevent people from becoming overweight by encouraging them to eat better and move more. The coalition government sets out in the White Paper, Healthy Lives, Healthy People: Our Strategy for Public Health in England, its plans to broaden the Change4Life programme to take a more holistic approach to childhood issues, for instance covering strategies to help parents talk to their children about other health issues and behaviour, such as alcohol. For further information on this campaign, follow the link below: www.nhs.uk/change4life/Pages/change-for-life.aspx The Change4Life campaign has recently been expanded to focus on adults to encourage them to increase their physical activity levels. For further information, follow the link below: http://www.nhs.uk/Change4Life/Pages/daily-activity-tips.aspx
NICE guidance
The guidance on the prevention, identification, assessment, treatment and weight management of overweight and obesity in adults and children was intended to provide recommendations on the clinical management of overweight and obesity in the NHS. It also provides guidance on primary prevention approaches aimed at supporting adults and children to maintain a healthy weight.
The guidance was published in December 2006 and can be accessed on the NICE website: http://www.nice.org.uk/guidance/CG43
5-A-Day programme
The 5-A-DAY programme was launched in March 2003 as part of the health promotion activity by the Department of Health to encourage people to eat more fruit and vegetables. It aims to increase fruit and vegetable consumption by: raising awareness of the health benefits through targeted communications and improving access to fruit and vegetables working with national, regional and local organisations.
The Food Standards Agency (FSA) Consumer Attitudes Survey 2007 showed that 79% of adults were aware that they should eat at least five portions of fruit and vegetables a day, up from 43% in 2000. There is continued support for the Programme from the coalition government. For further information, please see link: www.nhs.uk/5aday
Appendix D: Further information

This new report (published 23rd February 2012) draws together statistics on obesity, physical activity and diet. This report forms part of a suite of statistical reports covering, in addition, drug misuse, alcohol and smoking. Constructive comments on this report would be welcomed. Any questions concerning any data in this publication, or requests for further information, should be addressed to: The Contact Centre The Information Centre 1 Trevelyan Square Boar Lane Leeds West Yorkshire LS1 6AE Telephone: 0845 300 6016 Email: enquiries@ic.nhs.uk Press enquiries should be made to: Media Relations Manager: Telephone: 0845 300 6016 Email: enquiries@ic.nhs.uk This report is available on the internet at: www.ic.nhs.uk/pubs/opad12 Previous reports on Statistics on obesity, physical Activity and diet: England can be found on The NHS Information Centre website: http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/obesity Information on data sources used within this report are described in Appendix A and government plans and targets discussed in Appendix C. However further information regarding the topics discussed within this report maybe found from the following sources:
5-a-day
The 5-a-day website provides lots of useful information and resources for health professionals as well as the general public about healthy eating and fruit and vegetable consumption http://www.5aday.nhs.uk/
Annual Report of the Chief Medical Officer

Over the last 150 years, annual reports have been published by the Chief Medical Officer, almost every year. These reports provide an important record of the nations health and the major challenges faced by government in tackling the main problems. In the last twenty years or so, the annual report has also provided detailed accounts of a wide range of initiatives taken by the government on public health and in the NHS. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/DH_096206
Association for the Study of Obesity

The Association for the Study of Obesity (ASO) was founded in 1967 and is the UK's foremost organisation dedicated to the understanding and treatment of obesity. The ASO has three key objectives: To promote professional awareness of obesity and its impact on health. To educate and disseminate recent research on the causes, consequences, treatment, and prevention of obesity To prioritise obesity and provide opinion leadership in the UK. http://www.aso.org.uk
Eurostat
Data presented on BMI by European Union (EU) countries, collected by Eurostat uses Health Interview Surveys (HIS). The HIS data are collected in different years depending on the country, ranging from 1996 to 2003. There is no fixed periodicity in these kinds of health surveys. Very few countries have a yearly survey on these topics. Data are disseminated simultaneously to all interested parties through a database update and on Eurostat's website. There are other sources available which present international figures on BMI. A source of such data is the World Health Organisation (WHO). The source of BMI from WHO varies from country to country. The prevalence of obesity among EU countries is broadly similar between Eurostat and WHO. Eurostat. Available at: http://epp.eurostat.ec.europa.eu/portal/page/portal/eurostat/home
Food Standards Agency

The Food Standards Agency (FSA) is an independent government department set up by an Act of Parliament in 2000 to protect the public's health and consumer interests in relation to food. The FSA provides advice and information to the public and government on food safety from farm to fork, nutrition and diet. It also protects consumers through effective food enforcement and monitoring. Although the FSA is a government agency, it works at 'arm's length' from government because it does not report to a specific minister and is free to publish any advice it issues. http://www.food.gov.uk/
General Lifestyle Survey (formerly General Household Survey)

The General Lifestyle Survey (GLF) is a multi purpose continuous survey carried out by the Office of National Statistics (ONS) which collects information on a range of topics from people living in households in Great Britain. The survey started in 1971. http://www.statistics.gov.uk/statbase/product.asp?vlnk=5756
International Obesity TaskForce

The International Obesity TaskForce (IOTF) is a global network of expertise, a research-led think tank and advocacy arm of the IOTF. The IOTF is working to alert the world to the growing health crisis threatened by soaring levels of obesity. It works with the World Health Organisation, other NGOs and stakeholders to address this challenge. www.iotf.org
National Institute for Health and Clinical Excellence (NICE)

The NICE website includes some information and clinical guidelines on the prevention, identification, assessment and management of overweight and obesity in adults and children. http://www.nice.org.uk/CG43
National Obesity Forum

The National Obesity Forum (NOF) was established by medical practitioners in May 2000 to raise awareness of the growing health impact that being overweight or obese was having on patients and the NHS http://www.nationalobesityforum.org.uk/
National Child Measurement Programme

The National Child Measurement Programme (NCMP) weighs and measures children in Reception (aged 45 years) and Year 6 (aged 1011 years). The findings are used to inform local planning and delivery of services for children, and gather population-level surveillance data to allow analysis of trends in excess weight. The latest NCMP data, for the school year 2010/11, has been collected by The NHS Information Centre (IC) and a national report is available from: www.ic.nhs.uk/ncmp
Primary Care Management of Adult Obesity Dr Foster

The aim of the report Primary Care Management of Adult Obesity, published by Dr Foster, is to examine the degree to which Primary Care Organisations (PCOs) across the UK are currently tackling the problem of obesity. http://www.drfosterintelligence.co.uk/library/reports/obesityManagement.pdf
School Fruit and Vegetable Scheme

Under the scheme, all four to six year old children in Local Education Authority maintained infant, primary and special schools are now entitled to a free piece of fruit or vegetable each school day. It was introduced after the NHS Plan 2000 included a commitment to implement a national school fruit scheme by 2004. www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/FiveADay/FiveADaygeneralinforma tion/DH_4002149
Scientific Advisory Committee on Nutrition

The Scientific Advisory Committee on Nutrition (SACN) is an advisory committee of independent experts that provides advice to the Food Standards Agency and Department of Health as well as other government agencies and departments. Its remit includes matters concerning nutrient content of individual foods, advice on diet and the nutritional status of people. www.sacn.gov.uk/
Scottish Health Survey

The Scottish Health Survey provides information on the health and health-related behaviours of people living in private households in Scotland. Among the Surveys aims are to estimate the prevalence of a range of health conditions and to monitor progress towards Scottish health and dietary targets. The 2010 survey is the sixth in a series which began in 1995 with a survey of adults aged 16 to 64. The 1998 survey also included children aged 2 to15 and adults aged 65 to 74 for the first time. From 2003, the survey did not have any age limits and included children from 0 upwards and adults aged 16 and over. All six surveys were commissioned by what is now the Scottish Executive Health Department. The Scottish Health Survey 2010. Available at: http://www.scotland.gov.uk/Publications/2011/09/27084018/91
Securing Good Health for the Whole Population

Derek Wanless first report Securing our Future Health: Taking a Long-Term View was published in April 2002. This identified three scenarios for meeting the long-term financial and resource needs of the NHS for the next two decades, to 2022. In its response to the report, the government announced that it would address the fully engaged scenario identified by Mr Wanless. Under this scenario the level of public engagement in relation to health is high, life expectancy goes beyond current forecasts, health status improves dramatically, use of resources is more efficient and the health service is responsive with high rates of technology uptake. The scenario envisaged delivery of better health outcomes at less cost than the others considered. In April 2003, the then Prime Minister, the Chancellor and the Secretary of State for Health asked Derek Wanless, ex-Group Chief Executive of NatWest, to provide an update of the challenges in implementing the fully engaged scenario set out in his report on long-term health trends. Derek Wanless' final report "Securing Good Health for the Whole Population" was published on 25th February 2004. www.hm-treasury.gov.uk/consultations_and_legislation/wanless/consult_wanless04_final.cfm
South East Public Health Observatory

The South East Public Health Observatory (SEPHO) is one of nine regional observatories throughout England and Wales and is a member of the Association of Public Health Observatories (APHO). SEPHOs aim is to improve health and reduce inequalities in the South East region by providing information and support to local organisations, partners and stakeholders. As part of the PHO Choosing Health series, the report Choosing Health in the South East: Obesity defines obesity and overweight, its causes and impacts on health, and looks at this issue as it varies with geography, age, gender, ethnicity, etc. It also discusses obesity and overweight in children and interventions. http://www.sepho.org.uk/Download/Public/9783/1/SEPHO%20obesity%20report%20Nov%2005.pdf
Tackling child obesity

This report is based on a joint study conducted by the Audit Commission, the Healthcare Commission and the National Audit Office, one of a series that looks at the delivery chains between important national policy intentions (set out in government departments Public Service Agreement targets agreed with HM Treasury) and local delivery. www.nao.org.uk/publications/nao_reports/05-06/0506801.pdf
Time Use Survey

The UK Time Use Survey is conducted on behalf of a funding consortium consisting of: the Economic and Social Research Council; the Department of Culture, Media and Sport; the Department for Education and Skills; the Department of Health; the Department of Transport, Local Government and the Regions; and the Office for National Statistics. The main aim of the survey was to measure the amount of time spent by the UK population on various activities. The UK 2000 Time Use Survey was the first time that a major survey of this type has been conducted in the UK and as such provides an opportunity to inform a cross-section of policy areas as well as having interest for academia, social research centres and the advertising and retail sector. In 2000, the first Time Use Survey was carried out using a combination of questionnaires and diaries. In 2005, a pre-coded time use diary was used to collect the results from adults aged 16 and over as part of the National Statistics Omnibus Survey. The Omnibus diary results are compared with the data collected in the UK 2000 Time Use Survey. http://www.statistics.gov.uk/cci/article.asp?ID=1600
Welsh Health Survey 2010

The Welsh Health Survey is a source of information about the health of people living in Wales, the way they use health services, and the things that can affect their health and is produced by the Welsh Assembly Government. This survey replaced two previous surveys: the former Welsh Health Survey (undertaken in 1995 and 1998) and the former Health in Wales Survey (undertaken every two to three years between 1985 and 1996). Results from this survey are not comparable with those from the previous surveys because of differences in the questionnaires and the way the survey is
designed and conducted. One addition to the survey is the collection of some limited information on childrens health. More detailed information for children is collected from 2007 onwards. The Welsh Health Survey 2010. Available at: http://wales.gov.uk/docs/statistics/2011/110913healthsurvey10en.pdf
World Health Organisation

The World Health Organisation (WHO) have a created a global database on BMI. This database provides both national and sub-national adult underweight, overweight and obesity prevalence rates by country, year of survey and gender. The information is presented interactively as maps, tables, graphs and downloadable documents. www.who.int/bmi/index.jsp
Appendix E: United Kingdom Statistics Authority Assessment of the Statistics on Obesity, Physical Activity and Diet: England publication
During 2010, the Statistics on Obesity, Physical Activity and Diet: England report, along with the three other publications (smoking, alcohol and drug misuse) that comprise the Lifestyles Compendium Publications published by the NHS Information Centre underwent assessment by the United Kingdom Statistics Authority. Following assessment, the publications were designated continued National Statistics status (see below): The United Kingdom Statistics Authority has designated these statistics as National Statistics, subject to meeting the requirements below, in accordance with the Statistics and Registration Service Act 2007 and signifying compliance with the Code of Practice for Official Statistics. Designation can be broadly interpreted to mean that the statistics: meet identified user needs; are well explained and readily accessible; are produced according to sound methods; and are managed impartially and objectively in the public interest. Once statistics have been designated as National Statistics it is a statutory requirement that the Code of Practice shall continue to be observed. The designation of National Statistics status was subject to a number of requirements and the UKSA report also contained a number of suggestions for improvements. These, together with detail on how these addressed by the NHS IC are below:
Requirement 1 Take steps to develop a greater understanding of the use made of the statistics;
publish the relevant information and assumptions, and use them to better support the use of the statistics (para 3.2)
A public consultation was launched by the NHS Information Centre on 1 April 2011 and ran for 12 weeks until 24 June 2011. Responses have been collated and assessed. www.ic.nhs.uk/work-with-us/consultations/lifestyles-statistics-compendia-publications-consultation The consultation aimed to engage with users of the reports to develop further understanding of how the reports are used, by whom, and for what purposes in order to also ensure the reports maintain their relevance and usefulness. We place a feedback form on each of our statistical release web pages inviting comments and suggestions for improvements to our official statistics. A summary of queries and comments received by the statistical production team are published alongside this report.
Requirement 2 Include an explanation of the distinction between National Statistics, other official
statistics and statistics that are not official, and comment on the extent to which they are reliable (para 3.11). Addressed in the Introduction and Appendix A. A Data Quality statement accompanies this report.
Requirement 3 Determine the most appropriate format for the compendia, in

consultation with users (para 3.22). This was determined by the public consultation launched by the NHS Information Centre and was implemented from August onwards.
Requirement 4 Include the name of the responsible statistician in the Statistics

on Drug Misuse: England compendium (para 3.28). Actioned in Statistics on Drug Misuse: England, 2010 published on 27 January 2011, and has also been included in all subsequent publications since.
Requirement 5 Complete their Statement of Administrative Sources so that it

covers all the sources currently used (para 3.29). This has been completed and is available at: http://www.ic.nhs.uk/statistics-and-data-collections/publications-calendar/administrative-sources
Suggestion 1 Publish the information about users gained from the contact
centre and via the website (para 3.3). Aggregated information for this publication accompanies this report.
Suggestion 2 Seek user input into the data accuracy measures that would best meet user
needs (para 3.10). This was captured via the compendia consultation: www.ic.nhs.uk/work-with-us/consultations/lifestyles-statistics-compendia-publications-consultation
Suggestion 3 Review the graphs and tables in the compendia in order to make presentation
consistent (para 3.22). The results are reflected in this publication wherever possible. A copy of the full UKSA assessment report is available on the following link: http://www.statisticsauthority.gov.uk/assessment/assessment/assessment-reports/index.html
ISBN: 978-1-84636-664-2
This publication may be requested in large print or other formats. Responsible Statistician Paul Eastwood, Lifestyle Statistics Section Head For further information: www.ic.nhs.uk 0845 300 6016 enquiries@ic.nhs.uk
Copyright 2012 The Health and Social Care Information Centre, Lifestyles Statistics. All rights reserved. This work remains the sole and exclusive property of The Health and Social Care Information Centre and may only be reproduced where there is explicit reference to the ownership of The Health and Social Care Information Centre. This work may be re-used by NHS and government organisations without permission. This work is subject to the Re-Use of Public Sector Information Regulations and permission for commercial use must be obtained from the copyright holder.

Statistics On Obesity Physical Activity and Diet England 2012

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Statistics on obesity, physical activity and diet: England, 2012

Obesity among adults

Obesity among children

Physical activity among adults

Physical activity among children

76 90 106 110 116

1.2 Physical activity

1.4 Health Outcomes

1.5 United Kingdom Statistics Authority assessment

Obesity among adults

2.1.2 Measurement of BMI

2.1.1 Measurement of overweight and obesity

Obese including morbidly obese

2.1.3 Waist circumference

2.1.4 NICE risk categories

2.2.2 Waist circumference

2.2.3 Health risk associated with BMI and waist circumference

2.2 Overweight and obesity prevalence

2.3 Trends in obesity and overweight

2.5 Obesity and lifestyle habits

2.3.2 Waist circumference

2.4 Obesity and demographic characteristics

2.6 Obesity and physical activity

2.7 Geographical patterns in obesity

2.7.2 Quality and Outcomes Framework

2.7.3 National and international comparisons

2.8 The future

Obesity among children

3.2 Trends in overweight and obesity

3.1.1 Measurement of overweight and obesity among children

3.3 Relationship between obesity and income

3.4 Obesity and overweight prevalence by parental BMI

3.5 Obesity and Physical Activity

3.6 Regional, national and international comparisons

3.7 Attitudes to and knowledge of physical activity by BMI status

3.8 The future

Physical activity among adults

4.2 Meeting physical activity guidelines

4.2.1 Self-reported physical activity

4.2.2 Objective measures of physical activity

4.3 Physical fitness

4.4 Participation in different activities

4.4.2 Non-occupational activity

4.5 Geographical patterns in physical activity

Figure 4.1 Adults participation in sport 2010/11

4.5.2 Sport and active recreation by Local Authority

4.5.3 Physical Activity levels in Scotland and Wales

4.6 Sedentary time

4.7 Knowledge and attitudes towards physical activity

Physical activity among children

5.2.1 Self-reported physical activity

5.2 Meeting physical activity guidelines

5.2.2 Objective measures of physical activity

5.3 Types of physical activity

5.3.2 Other types of physical activity

5.4.1 Participation in PE and school sport

5.4.2 Time spent on PE and school sport

5.4 Participation in Physical Education and school sport

5.6 Sedentary behaviour

5.5 Parental participation

5.7 Attitudes and perceptions to physical activity

6.2 Adults diet